How Ebola is re-emerged?


On 26 December 2013, a 2-year-old boy in the remote Guinean village of Meliandou fell ill with a mysterious illness characterized by fever, black stools, and vomiting. He died 2 days later.

The appearance in West Africa of Zaire ebolavirus was initially reported in March 2014, in a rural area of Guinea close to its borders with Sierra Leone and Liberia. On August 24, 2014, the Democratic Republic of the Congo (DRC) Ministry of Health notified the World Health Organization (WHO) of an outbreak of Ebola virus disease (EVD) in Equateur Province. The Ebola virus epidemic that emerged in late 2013 in West Africa illustrates how a virus that previously affected only small groups of people, perhaps a few hundred, can sweep rapidly through an area to affect tens of thousands, and become extremely difficult to contain. A combination of factors including high population densities, closer contact with wild animals, high population mobility across porous borders, severe shortage of health care workers, weak healthcare system, and a slow response has led to the worst outbreak of Ebola.

According to WHO, thirty previously unknown diseases, such as HIV/AIDS, Ebola, hepatitis C, Lyme disease, Hantavirus pulmonary syndrome and Severe Acute Respiratory Syndrome (SARS) have emerged in the past 20 years. Since the 1970s, about 40 infectious diseases have been discovered, including , SARS, Ebola, MERS, chikungunya, avian flu, and swine flu.

What is the Emerging of Infectious Disease?


According to the WHO definition, an emerging disease is identified by the as “one that has appeared in a population for the first time, or that may have existed previously, but is rapidly increasing in incidence or geographic range.” As we can see in Ebola example, the term re-emerging indicates that the disease is emerging once again in the same or perhaps a different geographic area. The emergence or re-emergence of an infectious disease may be complicated by reservoirs of the disease (such as domesticated or wild animals) resulting in sporadic outbreaks a among humans. Variety of environmental factors may contribute to re/emergence of a particular disease, such as temperature, moisture, human food or animal feed sources, in some cases antimicrobial resistance etc.

When the last Ebola outbreak recognized?


An Ebola outbreak emerged in West Africa in December 2013 .Ebola is not new to Africa, and outbreaks have been confirmed as far back as 1976. The Ebola outbreaks occurred in the years of 2001, 2002 and 2007 also in Africa.

The re-emergence of Ebola in West Africa raised many questions such as, why once again the Ebola outbreak in West Africa? The WHO highlighted some factors:

Damaged public health infrastructures


Guinea, Liberia, and Sierra Leone, which are among the poorest countries in the world, had only recently emerged from years of civil war and unrest that left basic health infrastructures severely damaged or destroyed and created a cohort of young adults with little or no education.

Road systems, transportation services, and telecommunications are weak in all three countries, especially in rural settings. These weaknesses greatly delayed the transportation of patients to treatment centers and of samples to laboratories, the communication of alerts, reports, and calls for help, and public information campaigns.

High population mobility across porous borders


West Africa is characterized by a high degree of population movement across exceptionally porous borders. Recent studies estimate that population mobility in these countries is seven times higher than elsewhere in the world. To a large extent, poverty drives this mobility as people travel daily looking for work or food. Many extended West African families have relatives living in different countries. Population mobility created two significant impediments to control. The traditional custom of returning, often over long distances, to a native village to die and be buried near ancestors is another dimension of population movement that carries an especially high transmission risk. Prior to the outbreaks, the three countries had a ratio of only one to two doctors per nearly 100,000 population.

Including the CDC healthcare workers, many other International agencies help people in West Africa.

Cultural beliefs and behavioral practices


High-risk behaviors in the three countries have been similar to what has been seen during previous Ebola outbreaks in equatorial Africa, with adherence to ancestral funeral and burial rites singled out as fueling large explosions of new cases. Medical anthropologists have, however, noted that funeral and burial practices in West Africa are exceptionally high-risk.

Data available in August 2015, as reported by Guinea’s Ministry of Health, indicated that 60% of cases in that country could be linked to traditional burial and funeral practices. In November, WHO staff in Sierra Leone estimated that 80% of cases in that country were linked to these practices. In Liberia and Sierra Leone, where burial rites are reinforced by a number of secret societies, some mourners bathe in or anoint others with rinse water from the washing of corpses. Understudies of socially prominent members of these secret societies have been known to sleep near a highly infectious corpse for several nights, believing that doing so allows the transfer of powers.

Reliance on traditional healers


Traditional medicine has a long history in Africa. Even prior to the outbreaks, poor access to government-run health facilities made care by traditional healers or self-medication through pharmacies the preferred health care option for many, especially the poor. Many surges in new cases have been traced to contact with a traditional healer or herbalist or attendance at their funerals. Traditional healers forbid people from any kind of treatment by healthcare workers.

In the photo from the CDC webpage a traditional healer encourages people to step forward and test for HIV.


The current West African Ebola outbreak is the largest ever recorded and differs dramatically from prior outbreaks in its duration, number of people affected, and geographic extent.

Community resistance, strikes by health care workers


Control efforts in all three countries have been disrupted by community resistance, which has multiple causes. Fear and misperceptions about an unfamiliar disease have been well documented by medical anthropologists, who have also addressed the reasons why many refused to believe that Ebola was real.

People and their ancestors had been living in the same ecological environment for centuries, hunting the same wild animals in the same forest areas, and had never before seen a disease like Ebola.

 

Equally unfamiliar were the response measures, like disinfecting houses, setting up barriers and fever checks, and the invasion by foreigners dressed in what looked like spacesuits, who took people to hospitals or barricaded tent-like wards from which few returned.


Public health messages that fueled hopelessness and despair


Health messages issued to the public repeatedly emphasized that the disease was extremely serious and deadly, and had no vaccine, treatment, or cure. While intended to promote protective behaviors, these messages had the opposite effect.

If hospitals and “Western” medicine offered no treatments, therapies, or cures, families preferred to care for their loved ones at home.

Spread by international air travel


The importation of Ebola into Lagos, Nigeria on 20 July and Dallas, Texas on 30 September marked the first times that the virus entered a new country via air travelers. These events theoretically placed every city with an international airport at risk of an imported case.

 

The imported cases, which provoked intense media coverage and public anxiety, brought home the reality that all countries are at some degree of risk as long as intense virus transmission is occurring anywhere in the world – especially given the radically increased interdependence and interconnectedness that characterize this century.

A virus with different clinical and epidemiological features


Recent virological analyses have determined that the virus circulating in West Africa is genetically distinct from Zaire viruses seen in past outbreaks and in the 2014 outbreak in the Democratic Republic of Congo. As scientists have noted, the virus in West Africa takes a different clinical course with different epidemiological consequences, although these differences do not affect the infectious period, case fatality rate, or modes of transmission. As noted in a major study and commentary published in Science Magazine on 29 August, the virus’ genome – its genetic “identity card” – is changing “fairly quickly” in fixed ways. As the authors of the report concluded, “continued progression of this epidemic could afford an opportunity for viral adaptation, underscoring the need for rapid containment.”

The long duration of the outbreaks

The Ebola outbreak demonstrated the lack of international capacity to respond to a severe, sustained, and geographically dispersed public health crisis. Governments and their partners, including WHO, were overwhelmed by unprecedented demands driven by culture and geography as well as logistical challenges.

Hundreds of CDC staff, including epidemiologists with extensive experience in outbreak containment, were deployed to support surveillance, contact tracing, data management, laboratory testing, and health education. UNICEF worked to promote child health and safe childbirth in addition to taking the lead on social mobilization. IFRC used its vast network of volunteers to take on primary responsibility for safe and dignified burials.

Doing unfamiliar work

Many organizations and agencies took on technical work normally handled by public health experts. UNFPA, for example, undertook contact tracing. The charity Save the Children assumed responsibility for managing a treatment center built by the UK government in Kerry Town, Sierra Leone.

As the year drew to a close, several charities were struggling to care for Ebola orphans, estimated by some to number more than 30,000 in the three countries. Poverty, the heavy stigma attached to this disease, and the speed with which it can devastate a village made it difficult to find homes for orphaned children.

Finally, what we have learned from the Ebola remerging?

The unprecedented epidemic of Ebola virus disease (Ebola) in West Africa highlights the need for stronger systems for disease surveillance, response, and prevention worldwide related to emerging or re- emerging infections.

After a preventable and costly local and global delay, heroic efforts by clinicians and public health personnel and organizations from West Africa and throughout the world broke the cycle of exponential growth of the epidemic and prevented many deaths. The current Ebola virus outbreak is a dramatic illustration of the threat from emerging infectious diseases. The healthcare workers realized that the emergency health care system must be prepared for an evolving public health event of international significance such as this.

For more information please visit the following webpages :

www.cdc.gov/eid/page/background-goals www.bcm.edu/departments/molecular-virology-and-microbiology/emerging-infections-and-biodefense/emerging-infectious-diseases
www.ncbi.nlm.nih.gov/pmc/articles/PMC4267510/
www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/publichealth/The%202014%20Ebola%20Virus%20Outbreak.pdf
www.who.int/csr/disease/ebola/one-year-report/factors/en/
www.ncbi.nlm.nih.gov/pmc/articles/PMC4456362/
www.who.int/csr/disease/ebola/one-year-report/ebola-report-1-year.pdf
www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a6.htm