The Ebola virus outbreak, which has been smouldering in parts of west Africa since December 2013, took centre stage in the world’s media at the end of July with the news that two Americans who had been helping to treat patients in Liberia had caught the disease, and were subsequently brought to Emory University Hospital, Atlanta, GA, USA, for treatment. By Aug 11, 1843 cases of Ebola and 1013 deaths had occurred in Guinea, Liberia, Nigeria, and Sierra Leone, making this the largest recorded outbreak. The increase in cases shows no sign of abating, and on Aug 8, WHO declared the outbreak to be a public health emergency of international concern, a decision that activates numerous recommendations for WHO member countries under the International Health Regulations. Although this is the 25th outbreak since the disease was discovered in 1976, its unprecedented size brings into focus several issues around how the scientific community, governments, and the media handle such events. The high case fatality, terrible haemorrhagic symptoms, and lack of vaccine or cure explain the fear that Ebola provokes. Yet the notion of a global outbreak of Ebola, fostered by parts of the mass media, seems unjustified. Ebola can only be caught by direct contact with someone with symptoms or with their bodily fluids. Although the incubation period of 2–21 days means that a person incubating the disease might fly to any part of the world, once they became ill they would likely be treated in an institution with far better infection control than is available in most of sub-Saharan Africa. Identifying and isolating contacts is taxing, but simpler than if the disease had a respiratory route of transmission. Also, Ebola seldom affects people with the means to buy an airfare. It’s worth noting that human Ebola transmission has never occurred outside Africa. Sadly, the fragility of health systems is one reason why Ebola is proving hard to stop in west Africa. Sylvain Baize and colleagues reported in April that the Ebola outbreak originated in December 2013 in southeast Guinea bordering Liberia and Sierra Leone. Improved roads allowed the disease to travel quickly, and because Ebola was previously unknown in the region—and surveillance is non-existant—health-care workers did not recognise or have the means to manage the outbreak. This combination of factors meant that when Ebola was finally recognised in March it was present in the three countries. www.thelancet.com/infection Vol 14 September 2014

Until recently, the task of managing the outbreak has been left largely to national governments and nongovernmental organisations such as Médecins Sans Frontières. A surge in cases since June, the first case in Nigeria in July, and the illness of the two Americans have now triggered a more proactive response from the international community. WHO sent a team of experts at the end of June and has issued a call for infectioncontrol professionals to work in affected countries. The US Centers for Disease Control and Prevention has disease control experts in all four countries and intends to deploy an additional 50 staff within the next month. The World Bank has pledged up to US$200 million in emergency funding to affected countries. The two American health workers were given the experimental treatment ZMapp (dubbed “secret serum” in some reports, although it’s neither secret nor a serum) before evacuation from Liberia. This development raises ethical issues around use of experimental drugs and equity of access to treatment. Because Ebola is a potential agent of biological warfare, the US Government has funded development of ZMapp, which is a mixture of three humanised monoclonal antibodies against the Ebola virus produced in tobacco plants. The drug was effective in a monkey model of Ebola, but has not entered human trials. The US Food and Drug Administration has given approval for another government-funded drug, TKM-Ebola, which interferes with viral RNA, to be used in Ebola-infected patients. On Aug 12, a panel convened by WHO concluded that, in the circumstances of the Ebola outbreak, use of unproven treatments is ethical. This seems a laudable conclusion when death is the most likely outcome of infection. In reality, current supplies of ZMapp are exhausted after the donation to Liberia of enough drug to treat just two patients. The international community is only now catching up with the rapid spread and scale of the Ebola outbreak. The epidemic reinforces the need for nations to investment in health infrastructure and disease surveillance to keep pace with other developments in Africa. Efforts to contain Ebola should not divert resources from more mundane infections, such as malaria, which have a far higher long-term disease burden. ■ The Lancet Infectious Diseases

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Ebola in west Africa

Published Online August 15, 2014 http://dx.doi.org/10.1016/ S1473-3099(14)70785-6 For the WHO declaration see http://www.who.int/ mediacentre/news/ statements/2014/ ebola-20140808/en/# For Baize and colleagues’ report see http://www.nejm.org/doi/ full/10.1056/NEJMoa1404505 For treatment trials in monkey models of Ebola see http:// www.pnas.org/content/109/ 44/18030.long, http://stm. sciencemag.org/content/5/ 199/199ra113.full.html, and http://www.thelancet.com/ journals/lancet/article/PII S0140-6736%2810%29 60357-1/fulltext For the WHO ethics panel statement see http://www.who. int/mediacentre/news/ statements/2014/ebola-ethicalreview-summary/en/


Ebola in West Africa.

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