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Are we learning the lessons of the Ebola outbreak?
Newsdesk
Are we learning the lessons of the Ebola outbreak? The announcement of the end of the Ebola outbreak was almost immediately followed by the discovery of new case of the disease. Talha Burki reports. Even as WHO announced the end of the most recent Ebola outbreak in west Africa a new one had begun. The disease has been under control in the region for around a year. By the end of July, 2015, the three nations at the centre of the epidemic—Guinea, Liberia, and Sierra Leone—were seeing fewer than five new cases per week. Guinea was declared Ebola-free on Dec 29, 2015, after reporting no new cases over the previous 42 days (twice the incubation period for the disease). The previous month had seen a similar declaration made for Sierra Leone. On Jan 14, 2016, WHO announced that Liberia was also free of the disease. “This date marks the first time since the start of the epidemic 2 years ago that all three of the hardest-hit countries have reported zero cases”, affirmed WHO. But it cautioned that “more flare-ups are expected and that strong surveillance and response systems will be critical in the months to come”. The caveat proved prescient. The same day, 68 days into its mandatory 90 day period of enhanced surveillance, Sierra Leone confirmed that a 22-year-old woman had died
CDC/Science Photo Library
For the Ebola report see Health Policy Lancet 2015; 386: 2204–2221.
Ebola treatment centre in Guinea
296
from Ebola. WHO added that there was a “significant risk of further transmission”. The case marked the eleventh flare-up linked to reintroduction of the virus from one of the region’s 13 000 or so survivors. The situation is immeasurably improved from the height of the epidemic in late 2014, when west Africa was reporting close to 1000 cases per week (although fears that the caseload would hit 10 000 per week proved unfounded).
“...what will mark the end of this, or any future, Ebola epidemic?” The final toll should not be much higher than the current 28 637 cases and 11 315 deaths. But the disease’s reappearance does raise the question: if a prolonged period without clinical detection is insufficient, what will mark the end of this, or any future, Ebola epidemic? The answer depends on the survivors. The live virus has been isolated from semen 82 days after onset of the disease. Indeed, Ebola virus RNA can linger in semen for at least 284 days, but this need not imply that the virus remains alive and capable of infection. And without this information it is difficult to define policy. WHO has recommended Ebola survivors either abstain from sex for up to 6 months or use condoms. But abstinence is always a tough sell, and condom campaigns in west Africa have usually met with scant success. Besides, there are other compartments of the body where the virus can also persist. For how long remains unclear, nor is it apparent why some survivors continue to show traces of the virus in their bodily fluids, while others infected at the same time have cleared it entirely.
“We are far from Ebola being over in that area, mainly because the population that has been exposed is huge”, explains Médecins Sans Frontières’ Estrella Lasry. The epidemic infected most people in 2014; the majority of these survivors have been disease-free for upwards of a year—so the pool of contagion is diminishing. “We definitely do not have a ticking time-bomb that will cause another epidemic of the same magnitude”, said Lasry. She believes that the situation will settle into something akin to that which prevails in the Ebola-endemic parts of Africa. “Epidemics will pop up here and there, probably a little more frequently than in the Democratic Republic of the Congo and Uganda”, she said. Aside from the risk of reintroducing the disease, Ebola survivors already face an array of unpleasant possibilities after their recovery from the acute phase of the disease. Vision loss and conjunctivitis, joint and muscular pain, fatigue, headaches, and anorexia have all been reported, as well as psychological problems such as depression, post-traumatic stress disorder, and survivor guilt. The extent and longevity of these conditions has yet to be determined; little is known about Ebola survivors. Stigma is also an issue; around one-fifth of Ebola patients treated at Liberia’s Redemption Hospital reported having moved home to hide their status. Several programmes have been established for survivors, alongside cohort studies to explore the exact nature of the long-term effects of Ebola infection. Service provision is patchy. Specialist eye care, for example, is scarce, especially outside the capital cities. Sierra Leone is home to only two ophthalmologists. Indeed, health www.thelancet.com/infection Vol 16 March 2016
care in the region is in a wretched state. Brutal civil wars in Liberia and Sierra Leone, and chronic instability in neighbouring Guinea, left all three countries woefully unready to handle the systemic shock of Ebola. “There were not the surveillance systems, the response capabilities, the public health infrastructure, or diagnostic capabilities to handle something like Ebola”, said Harvard University’s Ashish Jha. But while the lack of resources and expertise certainly exacerbated matters, questions remain over the extent to which west Africa was avoidably ill-prepared for the advent of the unfamiliar pathogen. “For more than 20 years we have had a strategy from the big global actors to fund disease-specific vertical programmes”, explains Jha. “Sometimes this money has been used to build broader systems, but this is hard to do—the programmes are designed to really ensure that they focus on the disease at hand”. Of course, as Jha acknowledges, it is not the case that had the investments not been made in the vertical programmes, they would have been made in strengthening the healthcare system itself. It is more likely that the money would have left the health sector entirely. And despite, for example, the continuing low rates of HIV/AIDS in Sierra Leone, investment in the disease does make sense. “You have to put in measures of control when HIV is at low prevalence so that it does not become high prevalence”, points out Lasry. Nonetheless, Ebola viscerally demonstrated the consequences of underinvestment in health-care infrastructure. “We have to switch our mindset from vertical programmes into much broader systems—you cannot predict what is coming, and you need a system that is prepared for all kinds of events, not just single diseases”, concluded Jha. It was not just west Africa that was ill-prepared for Ebola. “Definitely the initial response of WHO and the global health community was slow and late www.thelancet.com/infection Vol 16 March 2016
and unadapted to the situation at the time, particularly in the early part of the epidemic”, said Lasry. “WHO’s role is to coordinate, eventually this happened, but it was very dependent on country and personnel”. An independent panel report published in The Lancet, co-authored by Jha, criticised WHO for prematurely withdrawing expert teams from the affected region, failing to adequately mobilise international support, and delaying the declaration of a global emergency until 5 months after the epidemic had first been reported. The criticism has been acknowledged by WHO. The organisation plans to establish a new programme dedicated to responding to emergencies such as Ebola. “The points have been taken on-board and Zika is providing a test case for WHO to be more agile, to be quicker about things, and to respond in real time and not later on”, said Peter Graaff, former head of the UN Mission for Ebola Emergency Response. Jha believes that it is too soon to draw any conclusions. “Now we are seeing a more engaged and responsive WHO, but the real test is what happens, say,
“Ebola viscerally demonstrated the consequences of underinvestment in health-care infrastructure” 2 years from now, when the media and political attention is turned away, and another outbreak happens”, he told The Lancet Infectious Diseases. Over the past few years, WHO has seen sharp cuts to its staff and funding. Moreover, roughly 80% of its funding is earmarked, a severe constraint on the organisation. “Someone needs to break this cycle, and it has to be WHO; if it reforms to become more accountable and transparent, this would build trust, and countries would no longer feel that they had to earmark funds”, said Jha. There are plenty of lessons to draw from the Ebola epidemic. The universal importance of robust surveillance systems supported by laboratory capacity, and responsive national
Wade Williams/AP/Press Association Images
Newsdesk
Eye examination of Ebola survivor
and international infrastructures, for one. “We are living in an incredibly interconnected world and we need a basic effective system that deals with what will become a far more common phenomena: a cross-national infectious disease outbreak”, adds Jha. Trickier to handle are the elements of a crisis that are not purely health-related. Unsafe burial practices helped facilitate Ebola’s spread, and the travel and trade restrictions imposed on west Africa, against WHO’s recommendations, might discourage some countries from publicising future emergencies. Perhaps the greatest lesson is that a public health crisis can rapidly sprawl into something far larger. “Guinea, Liberia, and Sierra Leone saw that the infectious disease outbreak not only devastated their health-care system but actually devastated their economy—it has set them back years”, explains Jha. “That is a lesson everyone else is learning too.” With hundreds of WHO field deployments and thousands of technical experts now scattered across west Africa, half a dozen rapid diagnostic tools, and a vaccine in phase 3 trials, none of which was the case 2 years ago, Ebola is unlikely to wreak again the same kind of havoc in the region. But other viruses are coming. It is not only west Africa that need be prepared.
Talha Burki 297
Are we learning the lessons of the Ebola outbreak? The announcement of the end of the Ebola outbreak was almost immediately followed by the discovery of new case of the disease. Talha Burki reports. Even as WHO announced the end of the most recent Ebola outbreak in west Africa a new one had begun. The disease has been under control in the region for around a year. By the end of July, 2015, the three nations at the centre of the epidemic—Guinea, Liberia, and Sierra Leone—were seeing fewer than five new cases per week. Guinea was declared Ebola-free on Dec 29, 2015, after reporting no new cases over the previous 42 days (twice the incubation period for the disease). The previous month had seen a similar declaration made for Sierra Leone. On Jan 14, 2016, WHO announced that Liberia was also free of the disease. “This date marks the first time since the start of the epidemic 2 years ago that all three of the hardest-hit countries have reported zero cases”, affirmed WHO. But it cautioned that “more flare-ups are expected and that strong surveillance and response systems will be critical in the months to come”. The caveat proved prescient. The same day, 68 days into its mandatory 90 day period of enhanced surveillance, Sierra Leone confirmed that a 22-year-old woman had died
CDC/Science Photo Library
For the Ebola report see Health Policy Lancet 2015; 386: 2204–2221.
Ebola treatment centre in Guinea
296
from Ebola. WHO added that there was a “significant risk of further transmission”. The case marked the eleventh flare-up linked to reintroduction of the virus from one of the region’s 13 000 or so survivors. The situation is immeasurably improved from the height of the epidemic in late 2014, when west Africa was reporting close to 1000 cases per week (although fears that the caseload would hit 10 000 per week proved unfounded).
“...what will mark the end of this, or any future, Ebola epidemic?” The final toll should not be much higher than the current 28 637 cases and 11 315 deaths. But the disease’s reappearance does raise the question: if a prolonged period without clinical detection is insufficient, what will mark the end of this, or any future, Ebola epidemic? The answer depends on the survivors. The live virus has been isolated from semen 82 days after onset of the disease. Indeed, Ebola virus RNA can linger in semen for at least 284 days, but this need not imply that the virus remains alive and capable of infection. And without this information it is difficult to define policy. WHO has recommended Ebola survivors either abstain from sex for up to 6 months or use condoms. But abstinence is always a tough sell, and condom campaigns in west Africa have usually met with scant success. Besides, there are other compartments of the body where the virus can also persist. For how long remains unclear, nor is it apparent why some survivors continue to show traces of the virus in their bodily fluids, while others infected at the same time have cleared it entirely.
“We are far from Ebola being over in that area, mainly because the population that has been exposed is huge”, explains Médecins Sans Frontières’ Estrella Lasry. The epidemic infected most people in 2014; the majority of these survivors have been disease-free for upwards of a year—so the pool of contagion is diminishing. “We definitely do not have a ticking time-bomb that will cause another epidemic of the same magnitude”, said Lasry. She believes that the situation will settle into something akin to that which prevails in the Ebola-endemic parts of Africa. “Epidemics will pop up here and there, probably a little more frequently than in the Democratic Republic of the Congo and Uganda”, she said. Aside from the risk of reintroducing the disease, Ebola survivors already face an array of unpleasant possibilities after their recovery from the acute phase of the disease. Vision loss and conjunctivitis, joint and muscular pain, fatigue, headaches, and anorexia have all been reported, as well as psychological problems such as depression, post-traumatic stress disorder, and survivor guilt. The extent and longevity of these conditions has yet to be determined; little is known about Ebola survivors. Stigma is also an issue; around one-fifth of Ebola patients treated at Liberia’s Redemption Hospital reported having moved home to hide their status. Several programmes have been established for survivors, alongside cohort studies to explore the exact nature of the long-term effects of Ebola infection. Service provision is patchy. Specialist eye care, for example, is scarce, especially outside the capital cities. Sierra Leone is home to only two ophthalmologists. Indeed, health www.thelancet.com/infection Vol 16 March 2016
care in the region is in a wretched state. Brutal civil wars in Liberia and Sierra Leone, and chronic instability in neighbouring Guinea, left all three countries woefully unready to handle the systemic shock of Ebola. “There were not the surveillance systems, the response capabilities, the public health infrastructure, or diagnostic capabilities to handle something like Ebola”, said Harvard University’s Ashish Jha. But while the lack of resources and expertise certainly exacerbated matters, questions remain over the extent to which west Africa was avoidably ill-prepared for the advent of the unfamiliar pathogen. “For more than 20 years we have had a strategy from the big global actors to fund disease-specific vertical programmes”, explains Jha. “Sometimes this money has been used to build broader systems, but this is hard to do—the programmes are designed to really ensure that they focus on the disease at hand”. Of course, as Jha acknowledges, it is not the case that had the investments not been made in the vertical programmes, they would have been made in strengthening the healthcare system itself. It is more likely that the money would have left the health sector entirely. And despite, for example, the continuing low rates of HIV/AIDS in Sierra Leone, investment in the disease does make sense. “You have to put in measures of control when HIV is at low prevalence so that it does not become high prevalence”, points out Lasry. Nonetheless, Ebola viscerally demonstrated the consequences of underinvestment in health-care infrastructure. “We have to switch our mindset from vertical programmes into much broader systems—you cannot predict what is coming, and you need a system that is prepared for all kinds of events, not just single diseases”, concluded Jha. It was not just west Africa that was ill-prepared for Ebola. “Definitely the initial response of WHO and the global health community was slow and late www.thelancet.com/infection Vol 16 March 2016
and unadapted to the situation at the time, particularly in the early part of the epidemic”, said Lasry. “WHO’s role is to coordinate, eventually this happened, but it was very dependent on country and personnel”. An independent panel report published in The Lancet, co-authored by Jha, criticised WHO for prematurely withdrawing expert teams from the affected region, failing to adequately mobilise international support, and delaying the declaration of a global emergency until 5 months after the epidemic had first been reported. The criticism has been acknowledged by WHO. The organisation plans to establish a new programme dedicated to responding to emergencies such as Ebola. “The points have been taken on-board and Zika is providing a test case for WHO to be more agile, to be quicker about things, and to respond in real time and not later on”, said Peter Graaff, former head of the UN Mission for Ebola Emergency Response. Jha believes that it is too soon to draw any conclusions. “Now we are seeing a more engaged and responsive WHO, but the real test is what happens, say,
“Ebola viscerally demonstrated the consequences of underinvestment in health-care infrastructure” 2 years from now, when the media and political attention is turned away, and another outbreak happens”, he told The Lancet Infectious Diseases. Over the past few years, WHO has seen sharp cuts to its staff and funding. Moreover, roughly 80% of its funding is earmarked, a severe constraint on the organisation. “Someone needs to break this cycle, and it has to be WHO; if it reforms to become more accountable and transparent, this would build trust, and countries would no longer feel that they had to earmark funds”, said Jha. There are plenty of lessons to draw from the Ebola epidemic. The universal importance of robust surveillance systems supported by laboratory capacity, and responsive national
Wade Williams/AP/Press Association Images
Newsdesk
Eye examination of Ebola survivor
and international infrastructures, for one. “We are living in an incredibly interconnected world and we need a basic effective system that deals with what will become a far more common phenomena: a cross-national infectious disease outbreak”, adds Jha. Trickier to handle are the elements of a crisis that are not purely health-related. Unsafe burial practices helped facilitate Ebola’s spread, and the travel and trade restrictions imposed on west Africa, against WHO’s recommendations, might discourage some countries from publicising future emergencies. Perhaps the greatest lesson is that a public health crisis can rapidly sprawl into something far larger. “Guinea, Liberia, and Sierra Leone saw that the infectious disease outbreak not only devastated their health-care system but actually devastated their economy—it has set them back years”, explains Jha. “That is a lesson everyone else is learning too.” With hundreds of WHO field deployments and thousands of technical experts now scattered across west Africa, half a dozen rapid diagnostic tools, and a vaccine in phase 3 trials, none of which was the case 2 years ago, Ebola is unlikely to wreak again the same kind of havoc in the region. But other viruses are coming. It is not only west Africa that need be prepared.
Talha Burki 297