Editorial
Will May 9, 2015, become a date celebrated in Liberia’s recent history? On that date—if current progress is maintained—it will have been 42 days since the last confirmed patient with Ebola virus disease was buried on March 28, and the country can be declared Ebola free. We will know by the time this Editorial is published. What of progress in eliminating Ebola from the other countries in west Africa with widespread transmission? The WHO Ebola Situation Report of May 6, lists 18 confirmed cases in the week to May 3, with nine in Guinea and nine in Sierra Leone, compared with 33 the previous week. By comparison, at the peak of the epidemic in the last quarter of 2014, around 1000 new cases were reported for some weeks. Encouragingly, of 55 districts in Guinea, Liberia, and Sierra Leone that have reported at least one Ebola case since the start of the outbreak, 39 have had no reports for more than 6 weeks. Similarly, no new infections in health workers have occurred for 2 consecutive weeks. However, concerns remain over deaths in the community only identified at post mortem, infections among people without known contact with previous cases, and frequent reports of unsafe burials, suggesting the need for additional community engagement, surveillance, and contact tracing. In total, the Ebola outbreak has caused 26 628 cases and 11 020 deaths in nine countries, with the vast majority of these (26 593 and 11 005, respectively) in the three worst affected countries of west Africa. The conference report in this issue gives additional detail of how Ebola has been managed on the ground. International efforts need to be maintained to quench the remaining embers of Ebola virus disease in west Africa, but what must then happen to strengthen health-care systems in Guinea, Liberia, and Sierra Leone, and in the countries that border them? The strategic response plan released by WHO on April 28 has as one of its priorities the safe reactivation and increased resilience of essential health services. It can be argued that the weak health systems that were in place when the Ebola outbreak started helped spread the epidemic because of their lack of capacity to detect and diagnose the disease or to manage severely ill patients. The strategic plan notes that government health expenditure was low and that “external funding was skewed towards millennium development goals www.thelancet.com/infection Vol 15 June 2015
with limited investments in core health systems functions”. Management of endemic diseases such as malaria has suffered because of the focus on Ebola over the past year: a modelling paper by Patrick Walker and colleagues in this journal estimates an additional 10 900 malaria-attributable deaths during the Ebola outbreak. The epidemic has undoubtedly had a detrimental effect on vaccination programmes, and we can only speculate as to its effect on care for respiratory and diarrhoeal diseases. Reactivated health services should focus—as the WHO strategic plan recommends—on providing a minimum set of clinical and public health services, including maternal, child, and reproductive health and vaccination programmes. National governments must work in concert with international donors and non-governmental organisations. Perhaps existing Ebola treatment centres could be repurposed towards the long-term goal of universal access to quality health care, but for this to happen the shortage of trained health-care workers will need to be overcome. Greatly improved capacity for disease surveillance and response is another necessity for improving resilience of health systems in the Ebola-affected and surrounding at-risk countries. Although such capacity needs to be developed at the national level, plans for a continentwide African Centres for Disease Prevention and Control (ACDC) are welcome. The ACDC, to be established in Addis Ababa under the auspices of the African Union, will act as a coordination and planning agency, modelling itself along the modest lines of the European Centre for Disease Prevention and Control. However, its budget of just US$6·9 million to the end of 2016, with 11 staff, seems wholly inadequate for the task at hand. Increased funding from governments within and outside Africa will be essential to guarantee long-term success of the agency. At the worldwide level, the aftermath of the Ebola outbreak must see a renewed focus on global health security, as detailed by David Heymann and colleagues in The Lancet. An infectious diseases event akin to the west Africa Ebola outbreak will undoubtedly happen again. Whereas memories of the horrors of the outbreak will fade, we should have learnt enough to put systems in place to be better prepared next time. ■ The Lancet Infectious Diseases
CDC/Nahid Bhadelia, M.D./Science Photo Library
The Ebola endgame, and what comes after
For the WHO Situation Report see http://apps.who.int/ebola/ en/ebola-situation-reports For the ECCMID conference report see News page 639 For the WHO strategic response plan see http://apps.who.int/iris/ bitstream/10665/163360/1/ 9789241508698_eng.pdf For more on Ebola and malaria mortality see Articles Lancet Infect Dis 2015; published online April 24. http://dx.doi. org/10.1016/S14733099(15)70124-6 For more on the ACDC see http://www.nature.com/news/ highway-to-health-1.17362 For more on Ebola and global health security see Public Policy Lancet 2015; 385: 1884–901
615
Will May 9, 2015, become a date celebrated in Liberia’s recent history? On that date—if current progress is maintained—it will have been 42 days since the last confirmed patient with Ebola virus disease was buried on March 28, and the country can be declared Ebola free. We will know by the time this Editorial is published. What of progress in eliminating Ebola from the other countries in west Africa with widespread transmission? The WHO Ebola Situation Report of May 6, lists 18 confirmed cases in the week to May 3, with nine in Guinea and nine in Sierra Leone, compared with 33 the previous week. By comparison, at the peak of the epidemic in the last quarter of 2014, around 1000 new cases were reported for some weeks. Encouragingly, of 55 districts in Guinea, Liberia, and Sierra Leone that have reported at least one Ebola case since the start of the outbreak, 39 have had no reports for more than 6 weeks. Similarly, no new infections in health workers have occurred for 2 consecutive weeks. However, concerns remain over deaths in the community only identified at post mortem, infections among people without known contact with previous cases, and frequent reports of unsafe burials, suggesting the need for additional community engagement, surveillance, and contact tracing. In total, the Ebola outbreak has caused 26 628 cases and 11 020 deaths in nine countries, with the vast majority of these (26 593 and 11 005, respectively) in the three worst affected countries of west Africa. The conference report in this issue gives additional detail of how Ebola has been managed on the ground. International efforts need to be maintained to quench the remaining embers of Ebola virus disease in west Africa, but what must then happen to strengthen health-care systems in Guinea, Liberia, and Sierra Leone, and in the countries that border them? The strategic response plan released by WHO on April 28 has as one of its priorities the safe reactivation and increased resilience of essential health services. It can be argued that the weak health systems that were in place when the Ebola outbreak started helped spread the epidemic because of their lack of capacity to detect and diagnose the disease or to manage severely ill patients. The strategic plan notes that government health expenditure was low and that “external funding was skewed towards millennium development goals www.thelancet.com/infection Vol 15 June 2015
with limited investments in core health systems functions”. Management of endemic diseases such as malaria has suffered because of the focus on Ebola over the past year: a modelling paper by Patrick Walker and colleagues in this journal estimates an additional 10 900 malaria-attributable deaths during the Ebola outbreak. The epidemic has undoubtedly had a detrimental effect on vaccination programmes, and we can only speculate as to its effect on care for respiratory and diarrhoeal diseases. Reactivated health services should focus—as the WHO strategic plan recommends—on providing a minimum set of clinical and public health services, including maternal, child, and reproductive health and vaccination programmes. National governments must work in concert with international donors and non-governmental organisations. Perhaps existing Ebola treatment centres could be repurposed towards the long-term goal of universal access to quality health care, but for this to happen the shortage of trained health-care workers will need to be overcome. Greatly improved capacity for disease surveillance and response is another necessity for improving resilience of health systems in the Ebola-affected and surrounding at-risk countries. Although such capacity needs to be developed at the national level, plans for a continentwide African Centres for Disease Prevention and Control (ACDC) are welcome. The ACDC, to be established in Addis Ababa under the auspices of the African Union, will act as a coordination and planning agency, modelling itself along the modest lines of the European Centre for Disease Prevention and Control. However, its budget of just US$6·9 million to the end of 2016, with 11 staff, seems wholly inadequate for the task at hand. Increased funding from governments within and outside Africa will be essential to guarantee long-term success of the agency. At the worldwide level, the aftermath of the Ebola outbreak must see a renewed focus on global health security, as detailed by David Heymann and colleagues in The Lancet. An infectious diseases event akin to the west Africa Ebola outbreak will undoubtedly happen again. Whereas memories of the horrors of the outbreak will fade, we should have learnt enough to put systems in place to be better prepared next time. ■ The Lancet Infectious Diseases
CDC/Nahid Bhadelia, M.D./Science Photo Library
The Ebola endgame, and what comes after
For the WHO Situation Report see http://apps.who.int/ebola/ en/ebola-situation-reports For the ECCMID conference report see News page 639 For the WHO strategic response plan see http://apps.who.int/iris/ bitstream/10665/163360/1/ 9789241508698_eng.pdf For more on Ebola and malaria mortality see Articles Lancet Infect Dis 2015; published online April 24. http://dx.doi. org/10.1016/S14733099(15)70124-6 For more on the ACDC see http://www.nature.com/news/ highway-to-health-1.17362 For more on Ebola and global health security see Public Policy Lancet 2015; 385: 1884–901
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