Ebola 1 year later: Hard lessons learned

In March 2014, Médecins Sans Frontières launched an emergency response in Guinea to tackle an Ebola outbreak that was affecting people throughout four rural districts and Conakry, the country’s capital

Health care workers on the ground identified it as the Zaire ebolavirus, the most aggressive and deadly strain of the virus. On March 31, MSF reported 122 Ebola cases and 78 deaths in Guinea, as well as suspected cases in Liberia and Sierra Leone.

At the time, MSF called it an “unprecedented Ebola epidemic.”

One year later, after approximately 25,000 cases of Ebola and more than 10,000 deaths in West Africa, the outbreak is showing signs of slowing down.

Many say the outbreak could have, and should have, ended by now.

“If there had been an earlier response when MSF first raised concern, the outbreak would be over by now, no doubt about it,” Gilles Van Cutsem, MD, MPH, medical coordinator for MSF in South Africa and Lesotho, told Infectious Disease News. “We saw it in Senegal, Mali and Nigeria. When there is a quick response, and we get to it while it’s still only in rural areas, we can stop it just after a few hundred cases.”

Infectious Disease News spoke with Van Cutsem and others to discuss what went wrong in handling the Ebola outbreak and the lessons learned that will prepare us for the next epidemic.

Slow response

Since the beginning of the Ebola outbreak, WHO has been criticized for its slow response, despite pleas from MSF for assistance.

“There was denial on the side of governments and also inaction from the international community,” Peter Piot, MD, PhD, professor and director of the London School of Hygiene & Tropical Medicine, said in an interview. “In the beginning, it was just MSF carrying the burden of dealing with Ebola. Governments came in later and now the situation is completely different.”

Piot co-discovered the Ebola virus in 1976 during the first outbreak in Zaire (now known as the Democratic Republic of the Congo). Since October, he said there has been effective leadership in the three West African countries, and WHO and other global partners have become more active in providing assistance in the form of supplies, manpower and funds.

“International solidarity was late, but it has had an impact,” Piot said. “We’ve seen a major decline in new Ebola infections and deaths, particularly in Liberia.”

WHO has acknowledged its slow response to the outbreak and has made efforts to address it. In January, its executive board unanimously adopted a resolution to overhaul its capacity to respond to global outbreaks. In a speech to the board during a special session on Ebola, WHO Director-General Margaret Chan, MD, said the outbreak drew attention to some shortcomings in WHO’s infrastructure.

“Ebola is a tragedy that has taught the world, including WHO, many lessons about how to prevent similar events in the future,” Chan said during her speech in Switzerland.

Game changing events

Capt. Inger K. Damon, MD, PhD, incident commander for the CDC’s Ebola Response Team, said there has never been an Ebola outbreak of this magnitude. According to the CDC, there has been a handful of Ebola outbreaks since 1976, and the highest number of cases in any one outbreak was 425. As a result, no one suspected this outbreak would be any different, which is a factor that led to the slow initial response.

Damon said trajectory models from WHO and the CDC were an important catalyst of the international response. The WHO data, published in the New England Journal of Medicine in September, projected more than 20,000 cases of Ebola by November if there were no improvements in control measures. The CDC data, published in MMWR, projected 1.4 million cases by mid-January if there were no changes.

“Those numbers, whether they came to fruition or not, were important in grabbing people’s attention and establishing that there was a need for an international, coordinated response,” Damon told Infectious Disease News.

There were other factors prompting the international community to ramp up its response to the Ebola outbreak, including an airline passenger from Liberia who entered Lagos, Nigeria, in July — the first time the virus entered a new country by air travel.

According to WHO, this led people worldwide “to anticipate an ‘apocalyptic’ urban outbreak.” The event prompted the formation of an emergency committee under the organization’s International Health Regulations. The committee unanimously agreed that the outbreak constituted a public health emergency of international concern.

In addition to Nigeria, cases of Ebola also sporadically popped up in the United States and Europe. These cases played a key role in the international response.

“The massive media coverage of these cases increased public pressure, and globally, people began to pay much more attention to Ebola,” Van Cutsem said. “It took some time, but countries started to understand that if they didn’t help to control the outbreak in West Africa, it would expand beyond West Africa and become a threat for other countries. An Ebola outbreak in the slums of Mumbai or Rio de Janeiro would not be as easy to control as it would have been in New York or Dallas.”

A lack of public trust

The slow response from WHO was a factor in the outbreak spiraling out of control, according to Emmanuel d’Harcourt, MD, MPH, senior health director of International Rescue Committee. However, it was not the only factor, and it probably was not the main factor, he said.

“WHO has been a very convenient scapegoat,” d’Harcourt told Infectious Disease News. “There have been lots of stories about what it hasn’t done right, but the truth is, everyone involved made mistakes. MSF has even reflected on the many things they would have done differently, but WHO’s failings are the only ones getting widespread attention.”

According to d’Harcourt, the problem that has had the greatest impact on the epidemic was the lack of trust between the people in West Africa, and those involved in the outbreak response, including government and local authorities and even nongovernmental organizations.

This is a problem that continues to fuel the epidemic in Sierra Leone and in Guinea, he added.

“It makes no sense to speak about an international response if you don’t have the basic ingredients locally,” d’Harcourt said. “It’s not that WHO couldn’t have done better — because they could have, as could have many others — but people are forgetting the fundamental problem that communities all over West Africa do not trust those who are supposed to care for them. That’s a huge problem not only for the Ebola epidemic, but also for all of the other health problems that they’re facing.”

David H. Peters, MD, DrPH, MPH, professor and chair of the department of international health at Johns Hopkins Bloomberg School of Public Health, said developing infrastructure, training health care workers, building clinics and sending medicines are certainly important interventions for any outbreak. However, community engagement and developing trust between the community and the responding authorities is even more critical.

“We should’ve known from the lessons of Ebola in the DRC that you need an early response, but you can’t just parachute in and start scaring people in the community,” Peters told Infectious Disease News. “What’s needed is for communities to be engaged for [the sake of] information gathering, case finding, behavior change and ownership of the epidemic. But community engagement and empowerment are consistently missing … and it’s a lesson that needs to be learned.”

D’Harcourt agreed, adding that building trust in the community requires sending in anthropologists and speaking with community leaders to determine the best way to interact with the public, rather than immediately focusing on circulating information through posters and the radio.

He also said it is important to realize that community leaders and other influential figures are not always the town mayors or government officials.

“We’ve learned that we need to be smarter about influencing a community,” d’Harcourt said. “If we had done that, the response would have been much more effective. We were so focused on getting the clinical treatment out there that we didn’t consider the sociological factors that would have improved the treatment and had a much more rapid impact.”

Most agree that this outbreak highlighted the need to strengthen health care systems in West Africa. However, there is much more involved than building clinics and providing drugs and treatment.

“It’s not just about physical infrastructure,” Peters said. “This outbreak highlighted the need for community engagement and trust to change behaviors to manage the outbreak. Successes came when public health and community leaders used available information and resources to change tactics. I’m not convinced that the people working on strengthening the health systems, particularly international agencies, have learned in a similar way.”

According to d’Harcourt, mistrust between the public and the government has been a persistent issue that has hindered the provision of adequate health care services in West Africa.

Disruption of health services

The epidemic put enormous stress on the health system in West Africa, which was already fragile, Peters said. Although there are very few data at this point, Peters said there has been at least a 20% to 30% reduction in coverage of routine services, such as antenatal care and immunizations.

“We knew right from the beginning that health facilities closed, people stopped attending clinics and many outreach activities stopped, so sharp declines in routine and preventive care were expected,” Peters said. “We don’t know yet what the impact will be on mortality, but there are clearly damaging effects beyond the trauma of Ebola.”

In a study recently published in Science, researchers found that health care disruptions in West Africa have resulted in decreased numbers of childhood vaccinations, doubling the number of people at risk for measles if an outbreak occurred. During a presentation at CROI 2015, researchers reported a 40% decline in outpatient HIV services from August to December in Guinea compared with the previous year.

This disruption was not because resources were diverted to Ebola, Van Cutsem said. Nor was it because other health issues were pushed aside, according to d’Harcourt. Instead, it was because the health system as a whole was considerably slowed down.

Van Cutsem said health services in Liberia and Sierra Leone were virtually shut down from August to December, and it is almost certain that more people have died of other diseases, such as malaria or childhood illnesses like pneumonia and diarrhea, because health care services were unavailable to them.

“Health care provision was severely affected just because people were scared to come to health facilities and because health care workers simply were not able to work, and in some cases, died,” d’Harcourt said. “It’s clear that there will be an impact on health within the next few months, but I hope it will be back to normal within a year. But that ‘normal’ was not good enough to begin with, so we need to do so much better than where we were before the epidemic.”

Damon said one of the most important lessons learned from the Ebola outbreak was not to underestimate the power of fear and uncertainty, especially under the threat of an emerging infectious disease.

“The outbreak caused so much fear and panic in the community and essentially shut down the health care system,” Damon said. “It highlights just how fragile the health care systems are and the need for a developed public health sensibility so that there is a system in place to rapidly respond to an emerging disease. These two issues will be the focus of the global health security agenda.”

The role of health care workers

Another important lesson is the value of health care workers and the need to protect and support them in terms of payment and decent working conditions, d’Harcourt said.

“Ebola made it clear that health care workers were left on the front lines with precious little equipment and support,” he said. “Hopefully this will change, and as it changes, it’s possible that more people will be drawn into the profession, and more people who are currently abroad or stuck in the capital to earn a living will be deployed to rural areas where they are needed more.”

In addition, health care workers were disproportionately affected by the Ebola outbreak. In a report in MMWR, researchers wrote that in Sierra Leone, the incidence of Ebola among health care workers was 103-fold greater than in the general population.

“There already were very few health care workers in Sierra Leone, and Ebola killed a large number of them,” Van Cutsem said.

Treatments and vaccines

Since the Ebola outbreak began, one of the most pressing issues has been treatment. To date, there are no pharmaceutical therapies with a proven benefit against the disease. There are several treatments under investigation, but these are in early phase trials.

“We wasted a lot of time because of regulatory obstacles, and now the number of Ebola cases is declining,” Piot said. “I’m hopeful that we will have data that will make sure that in the next epidemic, we can really offer antiviral treatment.”

One of the promising agents under investigation is ZMapp (Mapp Biopharmaceutical), a cocktail of three monoclonal antibodies. ZMapp was used to treat several patients with Ebola, but outside of a clinical trial. As a result, it is unknown whether the drug provided any benefit. The National Institute of Allergy and Infectious Diseases recently launched a randomized controlled trial of ZMapp and will enroll children and adults in Liberia.

Another agent, favipiravir (Toyama Chemical), also showed promise in the JIKI trial in Guinea. Data from that trial, presented at CROI 2015, suggested favipiravir, a nucleoside polyermase inhibitor, reduced mortality when given to patients with a lower viral load earlier in the course of the disease. It demonstrated no such benefit for patients with high viral loads who also had severe kidney failure.

In the meantime, supportive treatment, including IV fluids, balancing electrolytes, maintaining oxygen status and blood pressure, and treating other infections, remains the standard of care, according to the NIH.

Piot mentioned that there are several Ebola vaccines currently in development. Two have advanced to phase 2 in the PREVAIL trial in Liberia: the cAd3-EBOZ candidate vaccine co-developed by NIAID scientists and GlaxoSmithKline, and the VSV-ZEBOV candidate vaccine developed by the Public Health Agency of Canada and licensed to NewLink Genetics Corporation and Merck.

“If we have a vaccine, then we can immediately immunize health care workers, and that will change how we deal with Ebola,” Piot said. “The impact of Ebola goes way beyond the people who die — it completely undermines health services. Many health care workers have been killed by Ebola, so that’s where a vaccine would make an enormous difference.”

The end in sight

After several weeks without a case in Liberia, officials were hopeful that the end was in sight. However, a new case was reported in mid-March. Still, the trajectories of case numbers in Guinea and Sierra Leone are going in a positive direction.

“We’ve stopped giving ourselves strict deadlines and timelines, and we are responding quickly, learning and adapting as needed,” Damon said. “That strategy was quite effective in Liberia, and we have structures within the country to respond quickly to new cases. We also have adequate capacity to isolate and care for individuals who develop symptoms of Ebola in Sierra Leone and Guinea. There seems to be better knowledge and understanding about the disease within those countries.”

The outbreak, though improving, is not over, Piot said.

“What we might see is a long and bumpy tail to the epidemic, with an outbreak popping up here and there, perhaps around a funeral,” Piot said. “What worries me is that in both Guinea and Sierra Leone, cases are still being detected in people that come out of the blue. Nobody knew they were contacts. They were not found through contact tracing or active case finding. This means that there are transmission chains occurring underground that we don’t know about.”

Despite recent successes, the question remains whether the outbreak can be declared over by the end of 2015.

“That’s an optimistic scenario,” Van Cutsem said. “The number of new cases is decreasing, the response is better than it was 6 month ago, there are more resources, and the situation is better organized. It’s possible to end the epidemic this year, but I am not sure if it will.” – by Emily Shafer

References:

Kilmarx P, et al. MMWR. 2014;63:1168-1171.
Leuenberger D, et al. Abstract 103LB. Presented at: Conference on Retroviruses and Opportunistic Infections; Feb. 23-26, 2015; Seattle.
Meltzer M, et al. MMWR. 2014;63(supplement):1-14.
Sissoko D, et al. Abstract 103-ALB. Presented at: Conference on Retroviruses and Opportunistic Infections. Feb. 23-26, 2015; Seattle.
Takahashi S, et al. Science. 2015;doi:10.1126/science.aaa3438.
WHO Ebola Response Team. N Engl J Med. 2014;doi:10.1056/NEJMoa1411100.

For more information:

Emmanuel d’Harcourt, MD, MPH, can be reached at: harcourt@rescue.org.
Inger K. Damon, MD, PhD, can be reached through CDC media relations at media@cdc.gov.
David H. Peters, MD, DrPH, MPH, can be reached at: dpeters@jhu.edu.
Peter Piot, MD, PhD, can be reached at: director@lshtm.ac.uk.
Gilles Van Cutsem, MD, can be reached at: gilles.van.cutsem@brussels.msf.org.