AFR/RC64//9 1 August 2014
REGIONAL COMMITTEE FOR AFRICA Sixty-fourth session Cotonou, Republic of Benin, 1–5 September 2014 Provisional agenda item 14
ORIGINAL: ENGLISH
EBOLA VIRUS OUTBREAK IN WEST AFRICA: UPDATE AND LESSONS LEARNT
Report of the Secretariat CONTENTS Paragraphs INTRODUCTION ........................................................................................................................ 1–4 SITUATION ANALYSIS AND ACTIONS TAKEN .................................................................. 5–7 MAIN ISSUES AND LESSONS LEARNT ............................................................................... 8–12 ACTIONS PROPOSED ............................................................................................................ 13–19
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INTRODUCTION 1. Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe illness with a case fatality rate that can be as high as 90%.1 It is caused by the Ebola virus that was first isolated in 1976. The virus is transmitted by direct contact with the body fluids (including blood and sweat) and tissues of infected people and animals, while febrile and at post-mortem. Although the reservoir of the Ebola virus is not fully known, it is believed that fruit bats are its sources.2 Infection can occur through contact with infected animals such as chimpanzees, gorillas and forest antelopes (dead or alive).3 2. Past outbreaks of EVD have occurred primarily in remote villages in Central and West Africa, near tropical rainforests, specifically in the Republic of Congo (2001-2002, 2003, 2005), Cote d’Ivoire (1994), Democratic Republic of Congo (1976, 1977, 1995, 2007, 2008 -2009, and 2012), Gabon (1994, 1996-1997 2001-2002), Sudan (1976, 1979, and 2004) and Uganda (2000-2001, 20072008, 2011, and 2012). Almost 3000 cases of EVD with over 1900 deaths have been documented since the Ebola virus was first discovered. During outbreaks, people at highest risk of infection are health workers, family members of victims and people in close contact with EVD victims, dead or alive. EVD outbreaks can wreak havoc on families and communities. However, infection can be prevented or controlled through adherence to recommended protective measures in health care settings, in communities especially at gatherings, or in homes. No specific medicines or vaccines are available for use by people or animals. Patients who are severely ill require intensive supportive care. 3. Since March 2014, three countries in West Africa - Guinea, Liberia and Sierra Leone – have been experiencing an EVD outbreak. The first cases were reported from the Gueckedou District of Guinea on 2 March 2014. The first cases in Liberia were reported from Lofa District on 31 March 2014 while the first cases in Sierra Leone were reported from Kailahun District on 26 May 2014. 4. This document highlights the situation of the EVD outbreak in West Africa, summarizes the actions being taken to address the outbreak, identifies the main issues and challenges and proposes actions for accelerated response to the outbreak. SITUATION ANALYSIS AND ACTIONS TAKEN 5. The three countries in West Africa - Guinea, Liberia and Sierra Leone—have been experiencing the EVD outbreak since March 2014. Lately, Nigeria has reported one imported case of EVD that originated from Liberia. As at 30 July 2014, the cumulative number of reported EVD cases in the four countries is 1406 with 742 deaths. Guinea had reported 472 cases and 346 deaths; Liberia has reported 360 cases and 181 deaths; Sierra Leone has reported 574 cases and 215 deaths; and Nigeria has reported 1 case that resulted in death. 6. In response to the epidemic, the World Health Organization has disseminated guidelines and tools for preparedness and response to outbreaks, provided guidance and coordinated the updating of national response plans, and deployed multidisciplinary teams to accelerate the control of the outbreak and strengthen the core capacities of national health workers. Support has also been 1
2 3
World Health Organization. Ebola viral disease: fact sheet. Geneva, Switzerland: World Health Organization, 2014. Available at http://www.who.int/mediacentre/factsheets/fs103/en. http://www.who.int/mediacentre/factsheets/fs103/en/). Leroy EM, et al. Fruit bats as reservoirs of Ebola virus. Nature 2005;438: 575 –6. Technical Guidelines for Integrated Disease Surveillance and Response in the African Region, 2nd Edition, 2010.
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provided for the countries to set up appropriate treatment centres, including facilities for isolation of patients in order to minimize spread. Other partners are working in close collaboration with WHO in providing technical and financial support for response operations in the EVD-affected countries and for prevention and preparedness activities in countries at risk of the deadly disease. 7. The WHO convened a two-day emergency meeting of ministers of health of selected countries and partners, in Accra, Ghana, from 2 to 3 July 2014. The meeting provided an opportunity for participants to share experiences on the outbreak in the subregion; discuss key issues regarding the containment of the EVD outbreak in West Africa; and agree on appropriate interventions for preparedness and control of the outbreak. The meeting issued a communiqué and adopted a common intercountry strategy calling for accelerated response to the Ebola outbreak in West Africa. In addition, Heads of State and Government of the Economic Community of West Africa States (ECOWAS), during their Summit meeting in Accra in July 2014, decided to adopt a regional approach to containing and managing the EVD outbreak and directed that a Solidarity Fund be established to that end. A subregional Ebola Coordinating Centre has also been established in Guinea to coordinate the response operations and WHO staff from the various levels of the Organization were deployed to the Centre in July 2014. MAIN ISSUES AND LESSONS LEARNT 8. Inadequate public awareness leading to resistance: The current epidemic is the first major EBV outbreak reported in West Africa. There is still inadequate public awareness and lack of understanding among the general public and within the communities as regard the causes, the clinical presentation and the mode of transmission of the disease. This has led to fear, panic, denial, mistrust and rejection of proposed public health interventions. This situation is fuelled by deep-rooted cultural beliefs and practices regarding care for the sick and the dead and has contributed in no small measure to a high exposure of communities to the Ebola virus. Some communities consider that health care workers are interfering with their established cultural practices and this has resulted in lack of trust, limited use of treatment and care centres and high levels of deaths. 9. Inadequate capacity for early detection of and rapid response to the EVD outbreak: Generally, health workers at district and lower levels have weak capacity to identify and report priority diseases and conditions. They also have limited clinical experience in addition to the lack of laboratory facilities for confirmatory diagnosis of EVD. As a result, response to the EVD outbreak has been insufficient and untimely. Only a few countries in the Region have adequate laboratory facilities and technical capacity for confirmatory diagnosis of infectious diseases in general and emerging and dangerous pathogens in particular. Furthermore, the networks of national public health laboratories are not fully operational to ensure appropriate systems for safe and rapid shipment of biological specimens from the field to national reference laboratories. 10. Inadequate capacity for treatment and infection prevention and control (IPC): In general, health facilities especially in rural settings have limited capacity to provide effective clinical and nursing care. They have insufficient numbers of experienced staff and limited facilities for isolation of cases. There is inadequate supply of case management materials such as medicines and IPC materials including personal protective equipment (PPEs). Implementation of standard precautionary measures for infection control, including measures against unsafe injections, is far from adequate.
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11. Inadequate linkages between health facilities and communities: There has been limited engagement of communities by local health workers. Instances where health workers engage with opinion leaders, especially local traditional, religious and political leaders, to find locally-adapted and acceptable solutions have been limited. 12. Lack of resources and inadequate coordination and collaboration: Successful implementation of EVD outbreak response requires financial, human and material resources, which are often not readily available. The outbreak has put a huge demand on the existing resources that are already scarce. Strong national leadership and effective coordination of all stakeholders involved in the response is highly essential, yet the structures and capacity for this at the national and subnational levels remain weak in several countries. Countries lack a multidisciplinary and multisectoral team at national level for the control of the outbreak. The magnitude and geographical scale of the outbreak have posed serious challenges in terms of human capacity and financial, operational and logistic requirements and threatens international public health. Movements within and across borders have created difficulties in tracing and following up contacts while and mechanisms for cross-border information sharing and collaboration to effectively address the epidemic remain weak. ACTIONS PROPOSED Member States 13. Raise awareness and knowledge: Countries should increase awareness of EVD among policy-makers, health workers and the general population using appropriate information, education and communication tools. They should develop, update or review public health information products based on accurate information from fact sheets produced by WHO, and tailor them to various target populations and audiences, based on a careful assessment of their cultural beliefs and practices. 14. Strengthen national capacity to detect EVD outbreaks and provide response: Countries should ensure that all health care providers from public sectors and private sectors are duly trained and fully engaged in active surveillance. They should, within the framework of the Integrated Disease Surveillance and Response (IDSR) strategy, strengthen their EVD alert management systems to enable them to attend appropriately to calls, rumours and other information from the communities. Member States should strengthen the EVD diagnostic capacity of national reference laboratories to ensure short turnaround time. In addition, systems for safe and rapid shipment of biological specimen from the field to the national reference laboratory and external laboratories should be strengthened. All countries, especially those bordering the EVD-affected countries, should implement adequate epidemic prevention or preparedness measures in order to avert the spread of EVD. 15. Strengthen national capacity to provide care to patients and ensure effective infection prevention and control: Countries should improve the provision of effective clinical care to EVD patients under appropriate nursing procedures and enhance IPC practices in all health care settings. They should establish specific EVD treatment centres proximate to all major active foci of viral transmission. Training and mentoring of national and district level health care workers in EVD case management and IPC practices should be conducted. Experienced and trained clinicians should be deployed to affected sites to supervise local health workers. 16. Involve communities early in implementing preventive and control measures: Countries should establish a system of communication between health workers, patients on admission, their families, and community members. Countries should engage communities appropriately to
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participate in the outbreak response. Among others, the process of community involvement should begin with establishing open dialogue with opinion leaders such as traditional, religious and political leaders. The dialogue should enable sharing of information on the disease and its mode of transmission, and identify adequate means to prevent or stop transmission. 17. Enhance coordination and collaboration and scale up resource mobilization: Countries should strengthen multisectoral outbreak coordination structures at all levels, and conduct regular supportive supervision and monitoring in hotspot districts to review progress. They should put in place mechanisms to speed up the decision-making process among ministry of health, WHO and partners. Adequate resources should be mobilized to ensure effective implementation of outbreak response activities. It is also crucial for countries to ensure strengthening of cross-border and multisectoral collaboration including establishing a functional framework for joint cross-border outbreak control activities. WHO and Partners 18. Partners, technical agencies and public health institutions should participate actively in the response activities in line with the identified country priorities by providing technical and financial support for response operations in the EVD-affected countries as well as for prevention and preparedness in countries at risk of EVD. WHO will provide leadership in the coordination, at global, regional and country levels, of international partners supporting the development and implementation of national preparedness and response plans. WHO will continue to mobilize and deploy the required WHO staff and other experts and consultants, and collaborate with institutions and networks to support the response to the current EVD outbreak. WHO will advocate for additional resources at national and international levels to address EVD and other haemorrhagic fevers. 19. The Regional Committee is requested to examine this report and adopt the actions proposed.