Ebola Virus Critical Appraisal

The Ebola virus causes a severe haemorrhagic fever that has the potential to cause widespread fatalities for those affected. The 2014 outbreak of Ebola in West Africa was extraordinary in scale, resulting in 28,646 reported cases and over 11,000 fatalities. The virus appeared unique by the speed and nature in which it spread from West Africa to other countries. In this appraisal, the reaction, management and response of those involved in handling this outbreak will be discussed. It is important that the lessons learned from the world’s greatest Ebola epidemic are not forgotten. [1]

The virus Ebola belongs to the Filoviridae family. This family can be divided into three genera, Cuevavirus, Marburgvirus, and Ebolavirus. The latter can be further sub-divided into five main strains: Bundibugyo, Reston, Sudan, Taï Forest and Zaire. Of these five, Bundibugyo, Sudan and Zaire are responsible for the primary cause of the severe disease in humans with death resulting in 25% to 90% of cases. The Reston and Taï Forest strains of the virus result in disease in primates that are non-human. [2] The 2014 outbreak of Ebola was due to the Zaire strain, resulting in the largest Ebola epidemic in history. As a result of this widespread outbreak, a major international public health threat occurred leading to the first time in which the virus spread across numerous global borders. The very first cases reported of the disease originate from two separate outbreaks which occurred in 1976 in the Democratic Republic of the Congo and South Sudan. In the Congo, the first few cases were reported in a small village near the Ebola river, which then gave the disease its name. The primary symptoms of the Ebola virus are characterised by severe headache, fever, vomiting, fatigue, diarrhoea, unexplained haemorrhage, abdominal pain and discomfort, muscle pain and weakness. Any of the aforementioned symptoms may appear between 2 and 21 days of exposure to the virus. [1,3]

On March 10th, 2014, the ministry of health in the West African country of Guinea were informed of an outbreak of an unknown disease characterised by vomiting, severe fever and diarrhoea resulting in high fatalities. Two days later, Médecin Sans Frontières (MSF), which translated in English means “Doctors without Borders”, a humanitarian non-government organisation working in the area were also informed of this outbreak. On March 18th, an MSF team arrived on site to complete examinations of those affected with this violent disease. Epidemiological blood tests were sent to both Hamburg, Germany and Lyon, France to confirm the nature of the pathogenic organism. The tests confirmed the outbreak was a result of EVD (Ebola Virus Disease) and because of this, on March 23rd, 2014, the World Health Organisation (WHO) declared an Ebola outbreak. [4]

An analysis of the soon to be epidemic was traced back to a small village known as Meliandou situated in south-eastern Guinea, which falls on the border of Liberia and Sierra-Leone. The alleged index case resulted from the death of a 2-year-old who became suddenly ill and died only 4 days later, on the 2nd December 2013. After this, family members of the child suddenly fell ill and died. It is thought the virus spread rapidly, causing further infection in larger communities in the surrounding area. By the time the virus was confirmed as being EVD at the end of March 2014, there were already 111 suspected cases and 79 fatalities. [5]

On March 30th, 2014, the first cases were confirmed in Liberia, a country situated to the south of Guinea meaning the virus had spread across the border. This increased the need for border observation that the government had failed to carry out beforehand. The Liberian government responded by forming a task force comprising of the WHO, UNICEF and other non-governmental organisations (NGO). Following this, the US Centre for Disease Control (CDC) deployed teams to assist in the rapid response which included training of medical personnel, raising community awareness and enhanced surveillance. Within the next few weeks however, the WHO and CDC began retreating from Liberia believing the outbreak here to be small despite the continuous and ongoing transmission in neighbouring countries.

By May 2014, EVD cases appeared to be decreasing in Guinea, leading to MSF Ebola treatment centres (ETC) being closed. However, in other parts of the country new cases continued to be reported leading to the realisation that the number of cases hadn’t decreased at all, in fact many of the cases were hidden. This failure to communicate would have detrimental effects. On the 25th May 2014, the first case of EVD in Sierra-Leone was confirmed, meaning the disease had crossed yet another border. Within a month new cases spiked rapidly. MSF opened an ETC in Sierra-Leone, but like the others in Guinea, it became instantly overwhelmed. By mid-2014, the government in the UK stepped up and supported the development of the National Ebola response in Sierra-Leone. Together with other NGO’s like Save the Children, four more ETC’s with a capacity of 700 beds were created. [7] In the ETC’s, Ebola was treated with care and rehydration with oral and/or IV fluids coupled with the treatment of precise symptoms to help increase survival following WHO guidelines. [2]

In September 2014, one Guinean newspaper accused many foreign healthcare workers in treatment centres of a conspiracy involving the idea that this virus was purposely brought in to infect locals so organ harvesting could be carried out on fatalities that were not reported. This led to tensions between healthcare workers and the public, resulting in riots and violence. Data was poorly collected during the early period of the outbreak as many of the already struggling resources were used to treat the rapidly growing numbers of infected patients. It was not until August 8th, 2014, that WHO declared this outbreak as a public health emergency of international concern. [1,6]

Mistrust and a breakdown of communication between the authorities and local communities proved to be a common occurrence in all countries affected by EVD in West Africa. In late August 2014, many protests turned into riots as communities tried to fight for rights to bury their deceased loved ones who died from EVD as their bodies were taken away to prevent further deterioration of the epidemic. In a harsh response, the Liberian government made it against the law to harbour an infected person and if caught, the offender would go to prison for 2 years. In Sierra-Leone, mass quarantine proved controversial with large food shortages in quarantined areas forcing many people to rebel and escape. Both were heavy-handed approaches, which worsened the chances of keeping the disease contained.

The number of new cases in Guinea’s capital of Conakry were rising, with treatment centres admitting 22 patients daily. On October 23rd, 2014, the government publicised that $10,000 would be paid to those families of healthcare workers who had fallen fowl to the disease while helping others. If this money was used elsewhere to get the infection under control first before awarding compensation to the families, it may have improved the control of the disease. It was also noted that many locations previously disease free were now severely affected. Only 2 weeks later, the town of Siguiri bordering Mali reported increasing cases of EVD resulting in the spread of the virus into another country at an alarming rate. [8] Intense transmission continued in the early weeks of 2015, leading all countries involved struggling with treatment and bed space. Altogether, Guinea had a total of nine ETC’s set up and ran by the MSF and Red Cross organisations. The commencement and set up of new ETC’s seldom coincided with demand and supply. [5,6]

At the end of January 2015, the reported weekly cases of EVD in Guinea and Sierra-Leone began to fall to 50 new cases per week however numbers fluctuated. From April to June, the reported cases fell again to 20 new cases per week, with a final rapid drop in July. From August to October only very few new cases were reported. Sierra-Leone declared a state of being Ebola-free in November 2015, one year on from their epidemic peak.

A new vaccine for the treatment of Ebola proved highly defensive against the virus when being carried out in a key trial in Guinea. The vaccine also known as rVSV-ZEBOV, was studied in a clinical trial involving nearly 12,000 people during 2015. This recombinant vaccine consisted of a vesicular stomatitis virus that was engineered genetically to express a specific glycoprotein from the Zaire strain, in the hope of stimulating a neutral immune response to the Zaire infection. The vaccination was primarily developed by the Public Health Agency of Canada (PHAC). [9] Pre-epidemic, the vaccine was only licenced in non-human primates. In around 6,000 of the cases for those who received the vaccine, after 10 days or more Ebola seemed to disappear. This major trial was carried out by the WHO, together with Guinea’s Ministry of Health and MSF with a few other NGO’s. But it was not until much later in March 2016 that the vaccine could be used [2,9]

Guinea was declared Ebola-free on December 29th, 2015 after 42 days without any new cases being diagnosed. However, following this on March 16th, 2016, Guinean healthcare officials described three fatalities characterised with Ebola-like symptoms. The next day, investigators from WHO, UNICEF and CDC arrived to examine four relatives of the deceased, in which two tested positive for EVD. [1,7] These cases were speedily treated at a centre with quick deployment of epidemiologists, contact tracers, surveillance experts, vaccinators, an anthropologist and social mobilisers together working as a multi-healthcare professional response team. If this approach had of been applied at the start of suspected cases in March 2014, the scale of the epidemic may have been better controlled. The country of Guinea was again professed Ebola-free on 1st June 2016. [8] Liberia followed Guinea in becoming Ebola-free on 9th June 2016. Out of the three main countries affected by Ebola in West Africa, Sierra-Leone amounted to the highest number of fatalities, with the total appearing close to 4,000 deaths and over 14,000 infections. This led to Sierra-Leonne being the country with the largest amount of Ebola cases in history.

In conclusion, there were many factors that contributed to the failure of the responses and management of the Ebola outbreak in 2014, both at national and international levels. To begin, there was a delayed and inadequate response at an international level that was also poorly co-ordinated. The outbreak occurred at an unprecedented scale, meaning organisations may have been unsure as to how to handle a situation of this magnitude. The lack of communication between county’s as well as countries coupled with a shortage in healthcare workers also led to a disastrous state of events. [1,4] Geographical issues also played a role in the downfall of the situation. The highly porous borders and lack of surveillance made it virtually inevitable that the EVD would spread to another region. The lack of trust that the public placed in the government of their country from previous events of corruption and wars led to them ignoring advice and making the spread of the condition worse. Guinea, Sierra-Leone and Liberia are among the poorest countries in the world and they had only previously departed civil wars, leading their damaged health infrastructure unable to cope with the high level of cases. Pre-epidemic, the level of healthcare workers was at an all-time low, meaning if a disaster were to happen, failure was inevitable. Successful control of the outbreak relies on the application of several interventions, including management, thorough surveillance and contact tracing. A good laboratory team and safe burials are also key. Communicating efficiently with the community and educating them for risk factors, vaccinations and signs of infection is also vital when trying to manage an epidemic. This was a major failing of each government involved in the outbreak and in hindsight, many lives may have been saved as a result of better communication. [2]