World Report
Ebola in west Africa: learning the lessons The region has presented unforeseen challenges, and the three worst affected countries have put in place different response strategies. Anna Petherick reviews some of the lessons learned so far.
Too late Opportunities to contain the virus were lost soon after, largely because of a lack of trust between local communities and the officials and medical professionals trying to nip the epidemic in the bud. For a while, doctors and administrators knew the identity—and hence the seriousness—of their viral enemy, and the outbreak was restricted to a reasonably small area of busy trade where the borders of the three countries meet. Médecins Sans Frontières (MSF) hired anthropologists to try to get the message across in Guéckédou, the district at the epicentre, but locals would hide new cases and contacts did not want to be traced. In early April, a mob attacked an MSF treatment facility believing that its staff were introducing the disease to the community in Macenta, a www.thelancet.com Vol 385 February 14, 2015
town in the next-door prefecture to Guéckédou. By mid-June, a rumour became widespread that infection-control teams spraying chlorine were wearing head-to-toe protection because they were in fact spraying the disease’s causative agent. Riots ensued. Eventually, an army of 3000 heavily armed youths assembled in a mining town called Forecariah, leading WHO epidemiologists to flee for their lives.
“Surprisingly to some experts, no Level 3 emergency was declared—the UN classification of the most serious kind of humanitarian problem...” And when it became time to scream to the world that case loads were skyrocketing, and to call for substantial international backup, the message seemed muddled to those poised to step in. Surprisingly to some experts, no Level 3 emergency was declared—the UN classification of the most serious kind of humanitarian problem—and, as a result, the usual, international disaster response mechanisms were never triggered. Mostly behind the scenes, there has been heavy criticism of WHO’s apparent reluctance to acknowledge the scale of the crisis at a crucial juncture, by contrast with full blown praise for MSF, which reached out to the media and lobbied foreign governments while working hard at fighting the disease on the ground. As MSF’s advocacy spurred goodwill among foreign medical staff, this goodwill to help came up against a bottleneck in medical evacuation resources; only one company in the world, a US outfit called Phoenix, operates air ambulances that are equipped to transport Ebola patients.
For next time Huge praise is due to those who have responded to the Ebola outbreak in west Africa. At the same time, the retrospective analysis that is just beginning has already revealed several glaring lessons to be heeded next time. To be sure, there was no way of predicting that the most lethal form of the Ebola family, the Zaire species, would appear so far away from its usual range, and its dynamics had never previously been witnessed in urban settings, but there is a sense that the ball was somewhat dropped. Some of the lessons to be learned are specific to west Africa, some are specific to dealing with Ebola, and some are globally relevant. Ebola is not a particularly difficult disease to contain, as long as tried and tested containment methods are instigated promptly and completely. West Africa has various regional characteristics that exacerbated the challenge. The ratio of doctors to patients is about two per 100 000. Civil war and state-wide turmoil, mainly in the 1990s, still leave footprints in the damage to hospital facilities and to roads, and in a whole cohort of young adults who missed out on schooling
Published Online February 10, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60075-7 See Editorial page 578
Marcus DiPaola/NurPhoto/Corbis
The early history of the ongoing Ebola outbreak in west Africa is a salutary statement about the lack of infectious disease surveillance capacity in one of the world’s poorest regions. The 1 year anniversary of the first case passed in December, 2014, yet that of the first laboratory confirmation of the virus won’t be until March 23, 2015. In the intervening period last year, cholera and then Lassa fever were thought to be the more likely suspects. When the diagnosis finally arrived, it came not from a facility in the region, but from the Institut Pasteur in Lyon, France. By that stage, people had succumbed to the virus not only in Guinea, but also in two more countries, Sierra Leone and Liberia—a spread that was not, at that point, detected, investigated, or reported to WHO. These three countries have now each witnessed deaths in the thousands.
A Liberian Red Cross burial team working in Monrovia, October, 2014
591
World Report
Ahmed Jallanzo/epa/Corbis
graves were mushrooming in zones where locals refused investigations by foreign medical staff. New treatment beds were immediately being filled by previously unidentified patients, implying that many people were sick, and hidden, at home. Later in Guinea’s outbreak, when the number of cases again seemed to have declined, desperate patients who had heard stories of Guinea’s success flocked in from neighbouring countries, reigniting local transmission.
and limit their trust in political leaders. But most of all, the populations of west Africa are rampantly mobile. To have relatives that need regular visiting in nearby countries is commonplace, and people zip around, unimpeded by porous national borders. “Ebola stood still for us in the past, and we could set up an operational machine in one area”, explains Armand Sprecher, an MSF public health specialist who has worked in all three countries during this outbreak. “If you have a contact tracing system, what do you do when your contact picks up and moves 60 km away one morning without telling you? If Ebola moves from location A to location B, suddenly you need to duplicate everything.” This explains a large part of why the control systems were overrun so quickly. After the virus’s initial appearance far inland, Guinea provided the first example of urban Ebola. In rural settings, Ebola moves outwards in small steps. An urban environment means unpredictability, the realisation that the virus could crop up at any medical facility at any moment as people seeking help head towards the city from the hinterlands. The first flare up in Conakry, Guinea’s capital, seemed to have been successfully quelled by the end of April, as the government started counting down the recognised incubation period of 21 days, hoping for no new cases. And yet, for two reasons, the official statistics just didn’t seem right. Fresh 592
“Largely because of their histories of recent conflict, Sierra Leone and Liberia are more used to dealing with the UN and working with foreign partners.”
versus Sierra Leone’s softer, more developmental one. What he means, for example, is that whereas Liberia engaged in active case finding, by sending special Ebola teams into neighbourhoods every second day and knocking on doors to seek out newly infected people, Sierra Leone sought instead to motivate the community to come forward when someone fell sick. “It was a very intrusive way of engaging in Liberia”, he says, “but probably with hindsight, it was quite well adapted to certain urban settings”. The figures back this up: people who were Ebola-positive were more likely to survive if they were identified via active case finding, than if they took themselves to a treatment centre, adds Koch.
Different approaches
International response
Guinea has attempted to tackle Ebola differently to the two other worst-affected countries. Largely because of their histories of recent conflict, Sierra Leone and Liberia are more used to dealing with the UN and working with foreign partners. A comparatively strong sense of sovereignty in Guinea has not served it particularly well. By the end of 2014, only half of the planned treatment centres were operating, and Guinea’s weekly rate of new cases was higher than ever before. France has been increasingly lending assistance over the past 2 months. By contrast, Sierra Leone and Liberia both decided to accept foreign governments taking de-facto lead roles in their outbreak responses. The UK took the reigns in Sierra Leone, working alongside local authorities, while the USA did so in Liberia. Beyond that, there have been stylistic distinctions between how the two countries have sought to counter the disease’s spread. Vincent Koch, who is leading Oxfam’s Ebola response, describes Liberia’s harder, or more top-down, approach, facilitated by its more centralised government and outspoken President,
Perhaps the most instructive period for the purpose of retrospective examination, is when Ebola arrived in Monrovia. MSF had no more experts left to deploy. “We didn’t know how to stretch ourselves any thinner”, says Sprecher. “We had already been banging away in Guinea at that point for 3 or 4 months and already had operations opening up in Sierra Leone. We tried to handle Liberia by bolstering the Ministry of Health. When I showed up in Monrovia in early July, there were three of us. That’s not a whole lot.” The primary lesson so far has not been about the need for new response methods, but about human resources and coordination. Building new treatment centres, when it eventually happened, was an easy task next to training and supervising people to staff them. International help should have been mobilised sooner. For one reason or another, and despite its mandate, WHO was “not instrumental in triggering that realisation”, says one senior government adviser. Koch agrees, “In my view, they dropped the ball enormously”.
Anna Petherick www.thelancet.com Vol 385 February 14, 2015
Ebola in west Africa: learning the lessons The region has presented unforeseen challenges, and the three worst affected countries have put in place different response strategies. Anna Petherick reviews some of the lessons learned so far.
Too late Opportunities to contain the virus were lost soon after, largely because of a lack of trust between local communities and the officials and medical professionals trying to nip the epidemic in the bud. For a while, doctors and administrators knew the identity—and hence the seriousness—of their viral enemy, and the outbreak was restricted to a reasonably small area of busy trade where the borders of the three countries meet. Médecins Sans Frontières (MSF) hired anthropologists to try to get the message across in Guéckédou, the district at the epicentre, but locals would hide new cases and contacts did not want to be traced. In early April, a mob attacked an MSF treatment facility believing that its staff were introducing the disease to the community in Macenta, a www.thelancet.com Vol 385 February 14, 2015
town in the next-door prefecture to Guéckédou. By mid-June, a rumour became widespread that infection-control teams spraying chlorine were wearing head-to-toe protection because they were in fact spraying the disease’s causative agent. Riots ensued. Eventually, an army of 3000 heavily armed youths assembled in a mining town called Forecariah, leading WHO epidemiologists to flee for their lives.
“Surprisingly to some experts, no Level 3 emergency was declared—the UN classification of the most serious kind of humanitarian problem...” And when it became time to scream to the world that case loads were skyrocketing, and to call for substantial international backup, the message seemed muddled to those poised to step in. Surprisingly to some experts, no Level 3 emergency was declared—the UN classification of the most serious kind of humanitarian problem—and, as a result, the usual, international disaster response mechanisms were never triggered. Mostly behind the scenes, there has been heavy criticism of WHO’s apparent reluctance to acknowledge the scale of the crisis at a crucial juncture, by contrast with full blown praise for MSF, which reached out to the media and lobbied foreign governments while working hard at fighting the disease on the ground. As MSF’s advocacy spurred goodwill among foreign medical staff, this goodwill to help came up against a bottleneck in medical evacuation resources; only one company in the world, a US outfit called Phoenix, operates air ambulances that are equipped to transport Ebola patients.
For next time Huge praise is due to those who have responded to the Ebola outbreak in west Africa. At the same time, the retrospective analysis that is just beginning has already revealed several glaring lessons to be heeded next time. To be sure, there was no way of predicting that the most lethal form of the Ebola family, the Zaire species, would appear so far away from its usual range, and its dynamics had never previously been witnessed in urban settings, but there is a sense that the ball was somewhat dropped. Some of the lessons to be learned are specific to west Africa, some are specific to dealing with Ebola, and some are globally relevant. Ebola is not a particularly difficult disease to contain, as long as tried and tested containment methods are instigated promptly and completely. West Africa has various regional characteristics that exacerbated the challenge. The ratio of doctors to patients is about two per 100 000. Civil war and state-wide turmoil, mainly in the 1990s, still leave footprints in the damage to hospital facilities and to roads, and in a whole cohort of young adults who missed out on schooling
Published Online February 10, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60075-7 See Editorial page 578
Marcus DiPaola/NurPhoto/Corbis
The early history of the ongoing Ebola outbreak in west Africa is a salutary statement about the lack of infectious disease surveillance capacity in one of the world’s poorest regions. The 1 year anniversary of the first case passed in December, 2014, yet that of the first laboratory confirmation of the virus won’t be until March 23, 2015. In the intervening period last year, cholera and then Lassa fever were thought to be the more likely suspects. When the diagnosis finally arrived, it came not from a facility in the region, but from the Institut Pasteur in Lyon, France. By that stage, people had succumbed to the virus not only in Guinea, but also in two more countries, Sierra Leone and Liberia—a spread that was not, at that point, detected, investigated, or reported to WHO. These three countries have now each witnessed deaths in the thousands.
A Liberian Red Cross burial team working in Monrovia, October, 2014
591
World Report
Ahmed Jallanzo/epa/Corbis
graves were mushrooming in zones where locals refused investigations by foreign medical staff. New treatment beds were immediately being filled by previously unidentified patients, implying that many people were sick, and hidden, at home. Later in Guinea’s outbreak, when the number of cases again seemed to have declined, desperate patients who had heard stories of Guinea’s success flocked in from neighbouring countries, reigniting local transmission.
and limit their trust in political leaders. But most of all, the populations of west Africa are rampantly mobile. To have relatives that need regular visiting in nearby countries is commonplace, and people zip around, unimpeded by porous national borders. “Ebola stood still for us in the past, and we could set up an operational machine in one area”, explains Armand Sprecher, an MSF public health specialist who has worked in all three countries during this outbreak. “If you have a contact tracing system, what do you do when your contact picks up and moves 60 km away one morning without telling you? If Ebola moves from location A to location B, suddenly you need to duplicate everything.” This explains a large part of why the control systems were overrun so quickly. After the virus’s initial appearance far inland, Guinea provided the first example of urban Ebola. In rural settings, Ebola moves outwards in small steps. An urban environment means unpredictability, the realisation that the virus could crop up at any medical facility at any moment as people seeking help head towards the city from the hinterlands. The first flare up in Conakry, Guinea’s capital, seemed to have been successfully quelled by the end of April, as the government started counting down the recognised incubation period of 21 days, hoping for no new cases. And yet, for two reasons, the official statistics just didn’t seem right. Fresh 592
“Largely because of their histories of recent conflict, Sierra Leone and Liberia are more used to dealing with the UN and working with foreign partners.”
versus Sierra Leone’s softer, more developmental one. What he means, for example, is that whereas Liberia engaged in active case finding, by sending special Ebola teams into neighbourhoods every second day and knocking on doors to seek out newly infected people, Sierra Leone sought instead to motivate the community to come forward when someone fell sick. “It was a very intrusive way of engaging in Liberia”, he says, “but probably with hindsight, it was quite well adapted to certain urban settings”. The figures back this up: people who were Ebola-positive were more likely to survive if they were identified via active case finding, than if they took themselves to a treatment centre, adds Koch.
Different approaches
International response
Guinea has attempted to tackle Ebola differently to the two other worst-affected countries. Largely because of their histories of recent conflict, Sierra Leone and Liberia are more used to dealing with the UN and working with foreign partners. A comparatively strong sense of sovereignty in Guinea has not served it particularly well. By the end of 2014, only half of the planned treatment centres were operating, and Guinea’s weekly rate of new cases was higher than ever before. France has been increasingly lending assistance over the past 2 months. By contrast, Sierra Leone and Liberia both decided to accept foreign governments taking de-facto lead roles in their outbreak responses. The UK took the reigns in Sierra Leone, working alongside local authorities, while the USA did so in Liberia. Beyond that, there have been stylistic distinctions between how the two countries have sought to counter the disease’s spread. Vincent Koch, who is leading Oxfam’s Ebola response, describes Liberia’s harder, or more top-down, approach, facilitated by its more centralised government and outspoken President,
Perhaps the most instructive period for the purpose of retrospective examination, is when Ebola arrived in Monrovia. MSF had no more experts left to deploy. “We didn’t know how to stretch ourselves any thinner”, says Sprecher. “We had already been banging away in Guinea at that point for 3 or 4 months and already had operations opening up in Sierra Leone. We tried to handle Liberia by bolstering the Ministry of Health. When I showed up in Monrovia in early July, there were three of us. That’s not a whole lot.” The primary lesson so far has not been about the need for new response methods, but about human resources and coordination. Building new treatment centres, when it eventually happened, was an easy task next to training and supervising people to staff them. International help should have been mobilised sooner. For one reason or another, and despite its mandate, WHO was “not instrumental in triggering that realisation”, says one senior government adviser. Koch agrees, “In my view, they dropped the ball enormously”.
Anna Petherick www.thelancet.com Vol 385 February 14, 2015
