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Preparing for the next Ebola

Reflecting on the 2016 outbreak
With the recent West African Ebola epidemic declared over on January 14th 2016, much of the world is moving on. However now is the time to reflect on the outbreak and our response, both its successes and its failings, to ensure we’re prepared for the next epidemic.
Strengthening healthcare infrastructure

The foundation of an effective emergency response system is an effective basic healthcare system. Ebola hit hardest in countries which lacked an established robust healthcare system. Therefore investment in building epidemic defence systems must begin with investment in public health infrastructure and capabilities.

These resources can be successfully repurposed to tackle emergency situations. In Mali, an isolation facility intended for managing Lassa fever was used to receive suspected Ebola patients for monitoring, and high-quality laboratory facilities intended to safely handle samples from tuberculosis and HIV patients were used to conduct Ebola testing. In Nigeria, infrastructure which had been established to tackle polio was repurposed to track contacts and map transmission chains.

The most important healthcare resource are healthworkers themselves. Frontline healthworkers are the first line of defence in any epidemic situation; they provide diagnosis and treatment, they support containment, contact tracking and detection. Equipping frontline healthworkers with the tools and the skills that they need is not a simple task, but it is crucial to stemming the spread of future outbreaks.

Rapid response

Across West Africa, 11,315 people died in the outbreak.

The first cases were not identified as Ebola until 25th March 2014, months after the outbreak claimed its first victim- one year old Emile Ouamouno in December 2013. By the time the WHO declared an Ebola outbreak, 59 people had died.

By the time Ebola reached Nigeria, they had witnessed the devastation of its spread and were well aware of the potential impact of a poor response.

“When confirmation of Ebola virus as the causative agent was announced on 23 July, the news rocked public health communities all around the world. No one believed that effective contact tracing could be undertaken in a chaotic and densely populated city like Lagos, with many poor people living in crowded slums and a population that swelled and ebbed every day as people came to the city looking for work or returned home when unsuccessful. Many envisioned an urban apocalypse, with Nigeria seeding outbreaks in several other countries, as had happened in the past with the poliovirus.” [1]

A strong and immediate response prevented this bleak prediction. The government established an emergency operations centre, allocated funds, coordinated efforts of a range of partners, and shared information with the public to ease fears. 26,000 households were visited by 150 contact tracers, coordinated by 40 epidemiologists [2].

Tackling Ebola required the coordinated expertise and resources of a wide range of organisations, from the WHO to Ministries of Health, from the CDC to university laboratories, from research institutes to Medecin Sans Frontieres, from experts to volunteers.

This incredible integrated response resulted in Nigeria suffering just 19 Ebola cases, and 7 deaths.

Whilst celebrating this success we must also consider the staggeringly good luck which contributed to the limited spread. The individual who brought Ebola to Lagos was a diplomat who travelled by air; he had contact with many fewer people than he would have on public transport, and he received high quality healthcare in a private room [2]. We must take what lessons we can from past successes but also prepare to not be so lucky next time.

Diagnostics

Figure 1 shows the location of laboratories. To handle 28,637 cases of Ebola there were just 22 functional laboratories. When Mali placed six potential cases of Ebola, it sent samples for testing to Dakar, Senegal and Atlanta, USA [1].  

People stepped up to coordinate against the epidemic with vigour. Nations across Africa and the world, including Nigeria, Uganda, Cuba and the Democratic Republic of Congo, sent trained healthcare workers and doctors to affected countries. Many healthworkers lives were lost.

The most significant way in which we can pay tribute to those who lost their lives protecting others from Ebola is to provide better support to healthworkers. Diagnostic capacity must step up. The teaching hospital at the University of Lagos did a fantastic job of turning around testing in 24 hours [3], but for the healthworkers putting their lives on the line we must do better.

Turning around results in 24 minutes rather than 24 hours will enable healthworkers to act quickly. Rapid diagnostics would enable treatment initiation as soon as possible, vital to improving patient outcomes; they would support quick and decisive containment; they would give relief to worried families.

In order to provide testing in minutes for all at risk, no matter where they live, these rapid diagnostics must be mobile and able to overcome barriers such as poor infrastructure and the high cost of travel for patients to far flung health centres [4]. As with all testing of hazardous samples, they must test in a closed system to protect those running the diagnostic.

This diagnostic would also benefit from having a wide range of potential applications. Its routine use for infectious disease testing would mean that manufacturing facilities would be established, distribution routes would be formed, an in-country supply would be available, trained healthworkers would be well-practiced at using the device, and cloud-based networks would have been collecting and sharing data for some time.

Surveillance

In Mali a telephone hotline was established and fielded 6,000 calls a day, with meticulous recording used to map regions where information needed to be disseminated or tailored. It was systems like this which supported important case tracking work and informed resource mobilisation.

“The world needs a global warning and response system for outbreaks. (Though the World Health Organization [WHO] has a Global Outbreak Alert and Response Network, it is severely understaffed and underfunded.) Such a system could enable us to manage not only a naturally occurring epidemic, but also one ignited by a bioterror attack” Bill Gates, The Next Epidemic- Lessons from Ebola, New England Journal of Medicine [5].

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“We need to invest in better disease-surveillance and laboratory-testing capacity, for normal situations and for epidemics. Routine surveillance systems should be designed in such a way that they can detect early signs of an outbreak beyond their sentinel sites and be quickly scaled up during epidemics. They should be linked with national public health laboratories to enable robust monitoring and response. And the data derived from such testing need to be made public immediately.” [5] 

Such a system would be instrumental in tackling emerging infections, but its impact would be much broader. It could provide vital data on disease spread and the evolution of antimicrobial resistance, as stipulated in the World Health Organisation’s Antimicrobial Resistance Global Report

With thousands of mobile diagnostics distributed across the globe, all securely sharing pathogen data in real-time, healthworkers could be one step ahead of the next outbreak.

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Figure 1. Map showing the location of Ebola laboratories in West Africa

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Figure 2. Map showing the devastating spread of Ebola across West Africa

References

[1] WHO, “Successful Ebola responses in Nigeria, Senegal and Mali,” January 2015. [Online]. Available: http://www.who.int/csr/disease/ebola/one-year-report/nigeria/en/. [Accessed 28 April 2016].

[2] F. Ogunsola, “How Nigeria beat the ebola virus in three months,” The Conversation, 13 May 2015. [Online]. Available: http://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372. [Accessed 28 April 2016].

[3] C. Juma, “How Nigeria defeated Ebola,” The Guardian, 31 October 2014. [Online]. Available: http://www.theguardian.com/global-development-professionals-network/2014/oct/31/ebola-nigeria-state-public-sector-calestous-juma. [Accessed 28 April 2016].

[4] J. Agoada, “3 ways we can better prepare for the next Ebola outbreak,” Huffington Post, 18 November 2014. [Online]. Available: http://www.huffingtonpost.com/joseph-agoada/3-ways-we-can-better-prep_b_6179426.html. [Accessed 28 April 2016].

[5] B. Gates, “The Next Epidemic- Lessons from Ebola,” New England Journal of Medicine, vol. 372, pp. 1381 – 1384, 2015.

[6] WHO, “Antimicrobial Resistance Global Report”.


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