2014 Ebola outbreak

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This refers to the West African Ebola outbreak from late 2013 which became an epidemic although a smaller and not insignificant outbreak occurred separately in the Congo in 2014. (see timeline below). This was perceived to create a risk to other countries, and many countries established a response including e.g. airport screening, guidance to various settings about how to identify possible cases and what to do if they identify any. The outbreak was severe as it occurred in countries that had no previous experience, with very poor health intra-structure, with a tradition of funeral practices (explains 60-80% of cases) that encouraged dissemination including importation into urban environments where health infra structure had no history of good infection control practices despite past Lassa fever outbreaks. Further past outbreaks have been controlled in rural settings where international response is able to 'flood' the transmission chain. International capacity did not exist to respond to this urban public health crisis, although the issue that WHO systems were designed to respond to local, focal, short term health emergencies not global, sustained emergencies had been identified in a 2010 review of the response to the 2009 H1N1 influenza outbreak. Even international manufacturing capacity for personal protective equipment did not exist. Retrospective analysis of the 27 (out of 3400, 13 died in first year) Médecins Sans Frontières (MSF) staff who became infected has identified that most caught the virus in the community, rather than when caring for suspected/known cases. The case fatality rate has been 71% in those cared for in Africa and 26% for those treated or evacuated to a well resourced healthcare facility. International media coverage peaked in August when two American and one British healthcare worker required medical evacuation, in October when USA and Spain confirmed local transmission in healthcare workers who had been issued with inadequate equipment and in January when an UK nurse returning to the country was diagnosed with a controversial delay. WHO officially declared the end of active transmission in June 2016 although further cases may occur due to chronic carriage in recovered patients.

Contents

Guidance issued for the 2014 outbreak

See UK Ebola Outbreak guidance from 2014 for details of UK guidance etc. This has had several revisions.

Timeline of the 2014 outbreak

Timeline adapated from BMJ[1] and WHO report[2]

  • December 2012 - January 2013: Sudan strain outbreak in Uganda in 6 cases with 50% mortality.
  • 26 December 2013: Retrospectively identified first case in 2 year old child, in Meliandou in Guéckédou prefecture, Forest District, Guinea[3]. One of the house guests came from Sierra Leone and returned there when she became ill. She died and started a slow smoldering outbreak that was unrecognised for months.
  • 24 January 2014: First alert by head of the Meliandou health post. By then spread to relatives and staff Gueckedou hospital and into four subdistricts. Initial investigations by Médecins Sans Frontières (MSF) isolated bacteria but no follow up.
  • 1 February 2014: Virus reached Conakry, the capital of Guinea with a member of the index cases extended family who died in hospital
  • 13 March 2014: First alert of unidentified disease, suspected to be Lassa fever
  • 21 March 2014: Filovirus cause confirmed. Next day Ebola (Zaire strain) virus outbreak confirmed in Guinea.
  • 23 March 2014: WHO announces outbreak with 49 cases and 29 deaths to date. Ebola reported in Liberia at the end of the month
  • 30 March 2014:Two cases confirmed in Foya district, Lofa county, Liberia, near border with Guinea
  • 4 April 2014: Angry mob attacks MSF staff at Macenta
  • 10 May 2014: Burial of an infected traditional healer in Sokoma, Kailahun district, Sierra Leone, near border with Guinea sets off 365 Ebola related death chain of transmission which also spreads to Liberia
  • May 2014: Ebola reported in Sierra Leone. Despite official reports suggesting control in Guinea international responders suspect gross under reporting.
  • June 2014: Outbreak established in capital of Liberia, Monrovia with local healthcare resources overwhelmed by beginning of September. Kailahun, then city of Kenema in Sierra Leone outbreak recognised very quickly but healthcare facilities overwhelmed.
  • 23 June 2014: MSF declares that the outbreak is “out of control,” with more than 60 hotspots where the cases have been reported. 337 people were confirmed dead at that stage. First case reported in Freetown.
  • 20 July 2014: A diplomat arrives at Nigeria’s Lagos airport with Ebola symptoms (his sister had died from Ebola) , triggering concern worldwide that the disease could spread internationally by plane
  • 25 July 2014: Sierra Leone’s top Ebola doctor, Dr Sheik Umar Khan. succumbs to the disease and dies on 29th of July. More than 100 medical workers are known to be among the dead
  • 31 July 2014: WHO announces $100m to upscale the effort to contain the disease, and secretary general Margaret Chan warns of “catastrophic numbers of dead” if the disease is not brought under control. WHO staff and aid agencies on the ground say there are signs in some areas that numbers of new infections are beginning to fall. In total, 729 people are confirmed dead. The same day, the US announces the bringing forward of a clinical trial of a possible vaccine
  • 1 August 2014: Two infected US citizens are flown home from Liberia where they had been working with Ebola patients. They are treated with experimental treatment which subsequently seems to be very effective in early infection. One close contact of the Lagos case who fled the city, where he was under quarantine, is first treated at a Port Harcourt hotel.
  • 8 August 2014:WHO Emergency Committee chaired by Dr Sam Zaramba, meets to evaluate outbreak in context of international health regulations and next day WHO declares outbreak of international concern. Exit screening recommended but no trade or travel bans
  • 10 August 2014:Doctor who treated contact of first Nigerian case becomes ill in Port Harcourt unrecognised at time
  • 11 August 2014:WHO consensus statement that experimental vaccines and therapies ethically acceptable.
  • August 2014: International response in Kailahun suspended as community transmission had made it too dangerous. Health care workers in Kenema go on strike on 30th August. The tent response starts with WHO in Kenema so infected members of families can self-isolate.
  • 24 August 2014:Ebola outbreak in Boemde distrct, Equateur province, Congo
  • 29 August 2014:Ebola case confirmed in Dakar, Senegal in traveller by road from his home in Guinea.By good fortune Dakar had Pasteur Institute and ability to immediately create a dedicated isolation facility.
  • 2 September 2014:A minor Ebola outbreak in the Democratic Republic of Congo is confirmed to be a different strain from the West African outbreak[4].
  • 3 September 2014: A well characterised breakdown in infection control practices related to a patient breaking quarantine and hiding their potential infective status allows the Lagos. Nigeria outbreak to spread to Port Harcourt[5]. Many secondary care clinicians are potentially exposed emphasising the unprecedented high proportion of doctors, nurses, and other health care workers who have been infected[6]. A minor Ebola outbreak in the Democratic Republic of Congo is confirmed to be a different strain from the West African outbreak[7].
  • 18 September 2014:Eight member response team murdered.
  • 22 September 2014: Modelling by CDC demonstrates control possible with 70% compliance with standard isolation practice. Compliance with hospital isolation in some outbreak areas had been less than 10%. The model assumes 2.5 times under-reporting to WHO in the main outbreak countries as of 29th August based upon observation on the ground. This means over 21,000 cases will have occurred by the end of September. Cases in Liberia were doubling every 15–20 days, and those in Sierra Leone were doubling every 30–40 days[8]
  • 23 September 2014:Two members of a response team seriously injured when relatives uncovered appropriately buried grave and remove highly infectious body. Forecariah outbreak in western Guinea associated with 80% mortality and a mob of 3000 forcing all health care responders out of the town.
  • 30 September 2014: Case arrives unsuspected in Dallas, Texas. Lofa County, Liberia outbreak comes under control due to good community engagement.
  • 4 October 2014:Congo outbreak last case.
  • 10 October 2014: The first case of transmission outside Africa is confirmed in a nurse in Spain. Transmission to a healthcare worker in Texas is confirmed on 12 October. In both cases a breakdown in current best infection control practice is suspected. As of 8 October total Ebola virus disease cases were 8399 (with 4033 deaths ) reported to WHO from Guinea, Liberia, Nigeria, Senegal, Sierra Leone, Spain, and the USA.
  • 17 October 2014:Senegal declared Ebola free with only index case infected
  • 20 October 2014:Nigeria declared Ebola free proving that effective infection control and contract chasing measures for ebola can work in urban environments. The outbreak had 19 cases. 7 deaths, including the protocol officer who meet the index Nigerian case at the airport, and several healthcare workers who were not notified by the index patients of their contact history.
  • 23 October 2014: A 2 year old with Ebola is imported into Mali.
  • 25 October 2014: A Grand Imam from Siguiri prefecture in Guinea admitted to Pasteur Clinic. Bamako, Mali triggering chain of 7 cases and 5 deaths.
  • 21 November 2014: Congo outbreak declared over by WHO. This outbreak was controlled easily in classic manner due to rapid recognition and mobilisation of international response.
  • November 2014:WHO reports that Gonly 64 of 194 member states have the essential surveillance, data management, and other obligatory capacities of the International Health Regulations
  • December 2014:Convalescent sera trials commence. Favipiravir commences clinical trials. Several cases in international healthcare workers, most responding to experimental treatments and best supportive treatment. Outbreak starts to come under control in Guinea and Sierra Leone
  • 29 December 2014:Healthcare worker develops Ebola 1 day after return to UK from Sierra Leone
  • 19 January 2015: WHO declares outbreak in Mali officially over as 42 days have elapsed since last case
  • January 2015:Phase 2 trials Ebola vaccine (GlaxoSmithKline) commence. Merck vaccine production ramped up for release early 2015. Brincidofovir trials and field trails point of care diagnostic kits from February.
  • March 2015: So far over 23 500 reported cases with over 9500 reported deaths. Transmission still active but marked falls in Sierra Leone and Liberia. WHO declares UK Ebola free.
  • April 2015: Outbreak in Guinea continues to simmer.
  • 9 May 2015: WHO declares Liberia outbreak over (prematurely).
  • 14 June 2015:WHO reports 27,305 confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone, with 11 169 reported deaths as outbreak almost under control.
  • 30 June 2015:Case who had already died discovered in Liberia
  • 31 July 2015:Ring vaccination successfully interrupts transmission in Guinea. 7 new confirmed cases of EVD reported in the week to 26 July with 27,748 confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone and 11 279 reported deaths.
  • October 2015:Resurgent meningitis first confirmed as late risk in the UK after 9 months and semen remains infective for over 6 months.
  • 4 November 2015: Only remaining transmission chain is hoped to be around Forecariah, Guinea. To date 28,607 cases of EVD with 11,314 deaths assigned to this outbreak worldwide
  • 20 November 2015 Three new cases in Liberia.
  • 29 Dec 2015 Just over 2 years after index case WHO declares Guinea has no known Ebola transmission chains.
  • 15 Jan 2016 Sierra Leone reports a case a few hours after WHO reports no known transmission chains in West Africa.
  • 29 Mar 2016 WHO declares end of the Public Health Emergency of International Concern regarding the Ebola virus disease outbreak in West Africa.Sporadic cases continue, in particular in Guinea. There had been 28646 cases and 11323 deaths attributed to this date.
  • 27 Apr 2016 Results of phase 1 trials of the two major candidate vaccines for Ebola are reported formally
  • 9 June 2016 WHO declares the end of the most recent outbreak of Ebola virus disease in Liberia


WHO Ebola outbreak response

  • The faults in WHO response was subject to this formal report Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola Lancet DOI: http://dx.doi.org/10.1016/S0140-6736(15)00946-0. This resulted in ten recommendations:
    1. The global community must agree on a clear strategy to ensure that governments invest domestically in building such capacities and mobilise adequate external support to supplement efforts in poorer countries. This plan must be supported by a transparent central system for tracking and monitoring the results of these resource flows. Additionally, all governments must agree to regular, independent, external assessment of their core capacities.
    2. WHO should promote early reporting of outbreaks by commending countries that rapidly and publicly share information, while publishing lists of countries that delay reporting. Funders should create economic incentives for early reporting by committing to disburse emergency funds rapidly to assist countries when outbreaks strike and compensating for economic losses that might result. Additionally, WHO must confront governments that implement trade and travel restrictions without scientific justification, while developing industry-wide cooperation frameworks to ensure private firms such as airlines and shipping companies continue to provide crucial services during emergencies.
    3. A dedicated centre for outbreak response with strong technical capacity, a protected budget, and clear lines of accountability should be created at WHO, governed by a separate Board.
    4. A transparent and politically protected WHO Standing Emergency Committee should be delegated with the responsibility for declaring public health emergencies.
    5. An independent UN Accountability Commission should be created to do system-wide assessments of worldwide responses to major disease outbreaks.
    6. Governments, the scientific research community, industry, and non-governmental organisations must begin to develop a framework of norms and rules operating both during and between outbreaks to enable and accelerate research, govern the conduct of research, and ensure access to the benefits of research.
    7. Additionally, research funders should establish a worldwide research and development financing facility for outbreak-relevant drugs, vaccines, diagnostics, and non-pharmaceutical supplies (such as personal protective equipment) when commercial incentives are not appropriate.
    8. For a more timely response in the future, we recommend the creation of a Global Health Committee as part of the UN Security Council to expedite high-level leadership and systematically elevate political attention to health issues, recognising health as essential to human security.
    9. Additionally, decisive, time-bound governance reforms will be needed to rebuild trust in WHO in view of its failings during the Ebola epidemic. With respect to outbreak response, WHO should focus on four core functions: supporting national capacity building through technical advice; rapid early response and assessment of outbreaks (including potential emergency declarations); establishing technical norms, standards, and guidance; and convening the global community to set goals, mobilise resources, and negotiate rules. Beyond outbreaks, WHO should maintain its broad definition of health but substantially scale back its expansive range of activities to focus on core functions (to be defined through a process launched by the WHO Executive Board).
    10. The Executive Board should mandate good governance reforms, including establishing a freedom of information policy, an Inspector General's office, and human resource management reform, all to be implemented by an Interim Deputy for Managerial Reform by July 2017. In exchange for successful reforms, governments should finance most of the budget with untied funds in a new deal for a more focused WHO. Finally, member states should insist on a Director-General with the character and capacity to challenge even the most powerful governments when necessary to protect public health[9].
  • See WHO Ebola outbreak

References

  1. Arie S. Ebola: an opportunity for a clinical trial? BMJ (Clinical research ed.). 2014; 349:g4997.(Epub)
  2. One year into the Ebola epidemic: a deadly, tenacious and unforgiving virus WHO Jan 2015
  3. Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, Soropogui B, Sow MS, Keïta S, De Clerck H, Tiffany A, Dominguez G, Loua M, Traoré A, Kolié M, Malano ER, Heleze E, Bocquin A, Mély S, Raoul H, Caro V, Cadar D, Gabriel M, Pahlmann M, Tappe D, Schmidt-Chanasit J, Impouma B, Diallo AK, Formenty P, Van Herp M, Günther S. Emergence of Zaire Ebola Virus Disease in Guinea - Preliminary Report. The New England journal of medicine. 2014 Apr 16.(Epub ahead of print) (Link to article – subscription may be required.)
  4. Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo WHO 2 September 2014
  5. Ebola situation in Port Harcourt, Nigeria WHO 3 September 2014
  6. Unprecedented number of medical staff infected with Ebola WHO 24 August 2014
  7. Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo WHO 2 September 2014
  8. Meltzer MI et al. Estimating the Future Number of Cases in the Ebola Epidemic — Liberia and Sierra Leone, 2014–2015 CDC Morbidity and Mortality Weekly Report (MMWR) 22 Sept 2014
  9. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola Lancet DOI: http://dx.doi.org/10.1016/S0140-6736(15)00946-0