Ebola in West Africa: Issues with Elimination

Ebola in West Africa: Issues with Elimination

October 6, 2015
Ebola in West Africa: Issues with Elimination
Introduction
Issues Complicating Elimination
In January 2014, an Ebola outbreak began in Guinea, West
An “Ebola-Free” declaration does not necessarily remain
Africa. As of September 20, 2015, more than 28,000 people
permanent. For example, WHO announced that the Ebola
have been sickened by the disease, including over 11,000
outbreak had ended in Liberia in May 2015 and again in
deaths. Nearly all of those cases and deaths have occurred
September 2015 after health workers detected the disease in
in Guinea, Liberia, and Sierra Leone. Cases have also been
a 17-year-old male who died on June 28, 2015. According
discovered and contained in Mali, Nigeria, Senegal, as well
to WHO, successive outbreaks can occur due to human
as Britain, Italy, Spain, and the United States. The outbreak
contact with infected animals, sexual transmission, or a
is ongoing, but at a significantly decelerated pace (Error!
missed transmission chain. Four (Congo, Democratic
Reference source not found.). Since July 2015, weekly
Republic of Congo, Gabon, and Sudan) out of six countries
incidence has remained below 10 cases and in the week
(the aforementioned four and Uganda and Cote d’Ivoire)
ending on October 4, 2015, no new cases were detected for
that had previously had an Ebola outbreak experienced a
the first time since March 2014. The World Health
second one within three years.
Organization (WHO) announced that the outbreak had
ended in Liberia on September 3, 2015, and that no new
Although no new Ebola cases were detected in the week
cases had been detected in Sierra Leone since September
ending on October 4, 2015, new cases may emerge because
13, 2015.
over 500 people known to have had contact with an Ebola
patient have been lost to follow-up in Guinea. Several other
Figure 1. Weekly Ebola Cases: 01/2014-10/2015
high-risk contacts in Sierra Leone have also been lost to
(Guinea and Sierra Leone)
follow-up. A number of other key factors raise prospects
that Ebola may emerge again in the region, including:
 Persistence of Ebola virus in survivors. Health experts
do not yet know how long the virus can survive in the
body, and one of the cases that occurred in Sierra Leone
in mid-September appears to have resulted from contact
with a survivor (though epidemiologists are still
investigating the source of that case). Due to possible
sexual transmission of Ebola, WHO warns that Ebola
reemergence can occur beyond the 42 days. WHO
advises health workers in the three affected countries to
test semen samples of all male Ebola survivors monthly
until two negative results are obtained, and to advise
Ebola survivors either to abstain from sex or to use
condoms while engaging in sex until two negative
results are obtained. Pregnant women are also advised to

be tested for Ebola. It is unclear, however, whether these
Source: WHO, Ebola Situation Report, April 29, 2015 and October 7,
tests are being conducted, as Sierra Leone and Guinea
2015.
both use post-mortem testing as the primary method of
diagnosis.
Notes: The April 29, 2015, Ebola Situation Report was the last one
that included a graphic of weekly Ebola cases in Liberia, so Liberia is
 Heavy reliance on post-mortem diagnoses. In Sierra
not included in Figure 1.
Leone and Guinea, 77% and 87% of diagnostic tests,
respectively, are conducted on corpses. This means that
Ending the West Africa Ebola Outbreak
cases are detected after death, requiring field workers to
WHO considers an Ebola outbreak to have ended after 42
identify all previous contacts of the deceased. Heavy
days have passed since the last confirmed case has tested
reliance on post-mortem diagnosis and inadequate
negative twice. After an outbreak ends, WHO advises
access to rapid diagnostic tests heightens the likelihood
countries to maintain a system of heightened surveillance
that Ebola cases are being missed and that transmission
for a further 90 days to detect reemergence of the virus or
chains may be forming without notice.
undiagnosed cases. The West Africa Ebola outbreak will
have ended after the 42-day period has elapsed in the last
 Inadequate access to rapid diagnostic tests (RDTs).
affected country.
Heavy reliance on post-mortem diagnosis is linked, in
part, to inadequate access to rapid diagnostic tests,
particularly in private facilities. One of the cases that
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Ebola in West Africa: Issues with Elimination
emerged in Guinea in September 2015 went to a clinic
 distribution of 700,000 learning and teaching kits to
and was discharged without being tested for Ebola. The
more than 4,450 schools in Liberia.
10-year-old girl was diagnosed with Ebola after she
died. Efforts are underway to expand access to RDTs.
Issues for Congress
As noted, Congress has provided significant resources
U.S. Efforts to End the Outbreak
toward ending the West Africa Ebola outbreak. Nearly half
The 2015 Consolidated Appropriations Act (P.L. 113-235)
of these resources have been obligated, and the outbreak
provided roughly $5.4 billion in emergency funds for
appears to be nearly contained. Congress is closely
fighting Ebola outbreaks domestically and globally. Of
monitoring how the remaining resources are being
those funds, roughly $3.7 billion was designated for
obligated, as some Members would like to use any
international efforts, and Congress permitted the
unobligated balance for other health purposes.
Administration to spend an additional $532 million
domestically or globally. This section focuses on
When Congress first provided emergency funding for
international efforts.
containing the Ebola outbreak, some groups argued for a
portion of the resources to be used to strengthen the health
The Inspectors General (IG) from the U.S. Agency for
systems that were too weak to detect, respond to, or control
International Development (USAID), Department of
the outbreak. Supporters of this idea advocate for using any
Defense (DOD), Department of State (DOS), and
unobligated amounts toward strengthening the health
Department of Health and Human Services (HHS) released
systems in the affected countries. In the health sector, for
a report that detailed the amount of appropriated funds that
example, utilization of health services declined in all three
had been obligated and disbursed through June 30, 2015,
countries due to clinic closures and clinic avoidance. As a
for international Ebola responses. According to the report,
result, all three countries reported declines in childhood
the above agencies and departments had obligated more
immunizations and increases in measles cases. In Guinea,
than $1.7 billion on related efforts, of which roughly 40%
for example, an estimated 74,000 malaria cases were
($672.8 million) had been expended.
untreated in 2014; in Liberia, only 37% of women gave
birth in a health facility between May and August of 2014,
Although the number of U.S. officials based in the three
down from 52% during the same time period in the
countries has declined, U.S. agencies continued to support
previous year; and in Sierra Leone, 80% of clinics offering
11 Ebola treatment units (ETUs) and seven laboratories in
services for pregnant women with HIV closed. In all three
the region as of June 30, 2015. At the peak of the outbreak,
countries, health workers were among those who died
U.S. agencies were supporting 20 ETUs in Liberia alone.
during the outbreak. As of October 4, 2015, WHO reported
According to the IG report, U.S. assistance has also
that 513 health workers had died of Ebola in the three
supported
countries, including 100 in Guinea, 192 in Liberia, and 221
in Sierra Leone.
 establishment of a national Emergency Operation Center
(EOC) in Liberia and Sierra Leone, as well as provincial
Other supporters have argued for applying any unobligated
EOCs in Guinea;
amounts toward addressing other neglected global health
issues. Other observers have drawn attention to the setbacks
 safe burial activities by teams in Liberia (53), Sierra
that the countries experienced in their educational and
Leone (55), and Guinea (104);
economic sectors and are arguing for any unobligated funds
to go to these areas.
 provision of food and nutrition support to some 3
million people in the region;
Although this Ebola outbreak is waning, the disease can,
and probably will, reemerge in the region. The three
 training of nearly 6,000 health workers in Sierra Leone
affected countries have gained experience on containing the
and Guinea through partnerships with the International
outbreak, but their capacity to handle a future outbreak has
Organization for Migration (IOM), Catholic Relief
been severely hampered by Ebola deaths among health
Services (CRS), and other partners;
workers, economic losses, and health systems that have
been further weakened by the outbreak. Debates
 training of more than 1,000 community mobilizers and
surrounding the best approach for containing the outbreak
religious leaders who had reached 3,000 villages to raise
reflected long-standing arguments about whether to focus
awareness about Ebola and reduce stigma;
on a particular disease or on strengthening a health system.
Such debates may recur, especially if the disease reemerges.
 provision of approximately 435 metric tons of personal
For additional background information on the 2014 Ebola
protective equipment (PPE), water, sanitation, and
outbreak, see CRS Report R43697, U.S. and International
hygiene (WASH) supplies, and medicine;
Health Responses to the Ebola Outbreak in West Africa.
 distribution of 40 metric tons of disinfectant to Ebola
Tiaji Salaam-Blyther, Specialist in Global Health
responders;
IF10300
 provision of a daily meal to 245,000 children in Liberia
and Guinea, and nutritional support for more than 1
million people in Sierra Leone; and
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Ebola in West Africa: Issues with Elimination

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