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Western African Ebola epidemic

Situation map of the outbreak
Date	December 2013 – present
Location	Liberia, Sierra Leone, Guinea, Nigeria, Senegal
Casualties
Reported Cases / Deaths (as of 23 September 2014)  Total: 6,574 / 3,043  Liberia: 3,458 / 1,830  Sierra Leone: 2,021 / 557  Guinea: 1,074 / 648  Nigeria: 20 / 8  Senegal: 1 / 0 See notes for 23 Sept on Timeline Section

As of 2014, an epidemic of the Ebola virus disease (EVD) is ongoing in West Africa. The epidemic began in Guinea in December 2013. It then spread to Liberia, Sierra Leone, Nigeria and Senegal. The disease is caused by the Ebola virus (EBOV). It is the most severe outbreak of Ebola since the discovery of the virus in 1976. By September 2014 cases of EVD from this single outbreak exceeded the total of all cases from previous known outbreaks. The 2014 Democratic Republic of the Congo Ebola virus outbreak has been determined to be unrelated.

As of 23 September 2014, the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and local governments reported a total of 6,574 suspected cases and 3,043 deaths (3,614 cases and 1,789 deaths having been laboratory confirmed). Many experts believe that the official numbers substantially understate the size of the outbreak, due in part to community resistance to reporting cases, and a lack of personnel and equipment to investigate reports of the disease. As of 21 September WHO estimated that region's capacity for treating EVD is insufficient by the equivalent of 2,122 beds. Early WHO reports suggested an overall case fatality rate (CFR) estimate of 53%, considerably lower than an average of the rates reported from previous outbreaks, but on 23 September, they released a revised overall CFR estimate of 70% derived using data from patients with definitive clinical outcomes.

Affected countries have encountered many difficulties in their control efforts. In some areas, people have become suspicious of both the government and hospitals; some hospitals have been attacked by angry protestors who believe that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas that have been infected are areas of extreme poverty without even running water or soap to help control the spread of disease. Other factors include belief in traditional folk remedies, and cultural practices that predispose to physical contact with the deceased, especially death customs such as washing the body of the deceased. Some hospitals lack basic supplies and are understaffed. This has increased the chance of staff catching the virus themselves. In August, the WHO reported that ten percent of the dead have been health care workers.

By the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff. By September 2014, Médecins Sans Frontières, the largest NGO working in the affected regions, had grown increasingly critical of the international response. Speaking on 3 September, the international president spoke out concerning the lack of assistance from the United Nations member countries saying, "Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it." A United Nations spokesperson has stated "they could stop the Ebola outbreak in West Africa in 6 to 9 months, but only if a 'massive' global response is implemented." The Director-General of the WHO, Margaret Chan, called the outbreak "the largest, most complex and most severe we've ever seen" and said that it "is racing ahead of control efforts". On 12 September Chan stated, "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia."

Epidemiology

Initial outbreak (December 2013-March 2014)

Researchers believe that a 2-year-old boy was the index case of this Ebola virus disease outbreak after the child had a chance contact with a straw-coloured fruit bat.He died on 28 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those victims spread the disease to other villages. Although Ebola represents a major public health issue in sub-Saharan Africa, no cases had ever been reported in West Africa and the early cases were diagnosed as diseases more common to the area. Thus, the disease had several months to spread before it was recognized as Ebola.

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic fever that had sickened at least 35 people and killed 23. "We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola, because bushmeat is consumed in that region and Guinea is in the Ebola belt." On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts, with suspected cases in the neighbouring countries of Liberia and Sierra Leone being investigated. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March.

On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea's Ministry of Health and the WHO to lead an international response to the Ebola outbreak. On that date, the WHO reported 112 suspected and confirmed cases including 70 deaths. Two cases were reported from Liberia of people who had recently traveled to Guinea, and suspected cases in Liberia and Sierra Leone were being investigated. On 30 April, Guinea's Ministry of Health reported 221 suspected and confirmed cases including 146 deaths. The cases included 25 health care workers with 16 deaths. By late May, the outbreak had spread to Conakry, Guinea's capital, a city of about two million inhabitants. On 28 May, the total cases reported had reached 281 with 186 deaths.

Subsequent spread

In Liberia, the disease was reported in Lofa and Nimba counties in late March. The Ministry of Health and Social Welfare recorded possible cases in Margibi and Montserrado counties in mid-April. The first cases in Liberia's capital Monrovia were reported in mid-June.

The outbreak then spread into Sierra Leone and rapidly progressed. A study of the virus genomes determined that twelve residents, when attending a funeral in Guinea, became infected. They then carried the virus back home. On 25 May, the first cases in the Kailahun District, near the border with Guéckédou in Guinea, were reported. By 20 June, there were 158 suspected cases, mainly in Kailahun and the adjacent district of Kenema. Others were reported in the Kambia, Port Loko, and Western districts in the northwest of the country. By 17 July, the total number of suspected cases in the country stood at 442, and had overtaken those in Guinea and Liberia. By 20 July, cases of the disease had additionally been reported in the Bo District. The first case in Freetown, Sierra Leone's capital, was reported in late July.

The first death in Nigeria was reported on 25 July. A Liberian-American with Ebola flew from Liberia to Nigeria and died in Lagos soon after arrival. As part of the containment efforts, 353 possible contacts were monitored in Lagos and 451 in Port Harcourt. As of 22 September, the WHO reported a total of 20 cases with 8 deaths. They continue to monitor a few contacts, but the disease appears to now be contained in Nigeria.

On 29 August, the Senegalese Health minister Awa Marie Coll Seck announced the first case in Senegal. This was subsequently identified as a Guinean national who had been exposed to the virus and had been under surveillance, but had travelled to Dakar by road and fallen ill after arriving. This case subsequently recovered and on 22 September the WHO announced that all contacts had completed a 21-day follow-up with no further cases of Ebola in Senegal.

Countries with widespread transmission

Guinea

On 25 March, the World Health Organization (WHO) reported that Guinea's Ministry of Health had reported an outbreak of Ebola virus disease in four southeastern districts. In Guinea, a total of 86 suspected cases, including 59 deaths (case fatality ratio: 68.5%), had been reported as of 24 March. On 31 March, the U.S. Centers for Disease Control and Prevention (CDC) sent a five-person team to assist Guinea's Ministry of Health and the WHO to lead an international response to the Ebola outbreak.

Thinking that the virus was contained, Médecins Sans Frontières closed its treatment centers in May leaving only a small skeleton staff to handle the Macenta region. However, high numbers of new cases reappeared in the region in late August. According to Marc Poncin, a coordinator for MSF, the new cases were related to persons returning to Guinea from neighbouring Liberia or Sierra Leone.

On 18 September, it was reported that the bodies of a team of Guinean health and government officials, accompanied by journalists, who had been distributing Ebola information and doing disinfection work were found in a latrine in the town of Womey near Nzérékoré. The workers had been murdered by residents of the village after they initially went missing after a riot against the presence of the health education team. Government officials said "the bodies showed signs of being attacked with machetes and clubs" and "three of them had their throats slit."

It has been reported that some people in this area believe that health workers have been purposely spreading the disease to the people, while others believe that the disease does not exist. Riots recently broke out in the regional capital, Nzérékoré, when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it.

WHO estimated on 21 September that Guinea's capacity to treat EVD cases falls short by the equivalent of 40 beds.

Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March. By 23 July, the health ministry implemented measures to improve the country's response. On 27 July, Ellen Johnson Sirleaf, the Liberian president, announced that Liberia would close its borders, with the exception of a few crossing points, such as the airport, where screening centres would be established, and the worst-affected areas in the country would be placed under quarantine. Football events were banned, because large gatherings and the nature of the sport increase transmission risks. Three days after the borders were closed, Sirleaf announced the closure of all schools nationwide, including the University of Liberia, and a few communities were to be quarantined.

Sirleaf declared a state of emergency on 6 August, partly because the disease's weakening of the health care system has the potential to reduce the system's ability to treat routine diseases such as malaria; she noted that the state of emergency might require the "suspensions of certain rights and privileges". On the same day, the National Elections Commission announced that it would be unable to conduct the scheduled October 2014 senatorial election and requested postponement, one week after the leaders of various opposition parties had publicly taken different sides on the question. On 30 August, Liberia's Port Authority cancelled all "shore passes" for sailors from ships coming into the country's four seaports.

On 18 August, a mob of residents from West Point, an impoverished area of Monrovia, descended upon a local Ebola clinic to protest its presence. The protesters turned violent, threatening the caretakers, removing the infected patients, and looting the clinic of its supplies, including blood-stained bed sheets and mattresses. Police and aid workers expressed fear that this would lead to mass infections of Ebola in West Point. On 19 August, the Liberian government quarantined the entirety of West Point and issued a curfew state-wide. Violence again broke out on 22 August after the military fired on protesting crowds. The quarantine blockade of the West Point area was lifted on 30 August. The Information Minister, Lewis Brown, said that this step was taken to ease efforts to screen, test, and treat residents.

On 20 September, Liberia opened a new 150 bed treatment unit clinic in Monrovia. At the opening ceremony of the Old Island Clinic on Bushrod Island six ambulances were already waiting with potential patients. In addition, the patients were already waiting by the clinic after making their way on foot with the help of relatives. Two days later 112 beds were already filled with 46 patients testing positive for Ebola, while the rest were admitted for observation.

WHO estimated on 21 September that Liberia's capacity to treat EVD cases falls short by the equivalent of 1,550 beds.

Sierra Leone

The first person reported infected in the spread to Sierra Leone of this outbreak was a tribal healer. She had treated an infected person(s) and died on 26 May. According to tribal tradition, her body was washed for burial and this appears to have led to infections in women from neighboring towns. On 31 March, Sierra Leone declared a state of emergency and instituted measures to screen travelers from Guinea and Liberia. On 30 July, the government began to deploy troops to implement quarantines.

On 29 July, well-known physician Sheik Umar Khan, Sierra Leone's only expert on hemorrhagic fever, died after contacting Ebola at his clinic in Kenema. Khan had long worked with Lassa fever, a disease that kills over 5,000 a year in Africa. He had expanded his clinic to accept Ebola patients. Sierra Leone's President, Ernest Bai Koroma, celebrated Khan as a "national hero".

In August, awareness campaigns in Freetown, Sierra Leone's capital, were delivered over the radio and through loudspeakers. Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. At the time the law was enacted, a top parliamentarian was critical of failures by neighboring countries to stop the outbreak.

In an attempt to control the disease, Sierra Leone imposed a three-day lockdown on its population from 19 to 21 September. During this period 28,500 trained community workers and volunteers went door-to-door providing information on how to prevent infection, as well as setting up community Ebola surveillance teams. On 22 September, government officials said that the three day lock down had obtained its objective and would not be extended. Eighty percent of targeted households were reached in the operation. A total of around 150 new cases were uncovered, although reports from remote locations had not yet been received.

On 25 September, the government added three more districts under "isolation," in an effort to contain the spread. The districts include Port Loko, Bombali, and Moyamba. This brings the total areas under isolation to five, including the outbreak "hot spots" Kenema and Kailahun which were already in isolation. Only deliveries and essential services were to be allowed in and out. A sharp rise in cases in these areas was noted by the WHO.

WHO estimated on 21 September that Sierra Leone's capacity to treat EVD cases falls short by the equivalent of 532 beds.

Countries with local transmission

Nigeria

Nigeria Ebola areas-2014

Nigeria Situation Map as of 5 September 2014
Date	July 2014 – present
Casualties
Cases / Deaths (as of 21 September 2014)  Nigeria: 20 / 8

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria's former capital Lagos on 20 July. Sawyer became violently ill upon arriving at the airport and died five days later. In response, the Nigerian government observed all of Sawyer's contacts for signs of infection and increased surveillance at all entry points to the country. On 6 August, the Nigerian health minister told reporters, "Yesterday the first known Nigerian to die of Ebola was recorded. This was one of the nurses that attended to the Liberian. The other five cases are being treated at an isolation ward." .

On 9 August, the Nigerian National Health Research Ethics Committee issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria and supporting the use of non-validated treatments without prior review and approval by a health research ethics committee. Other than increased surveillance at the country’s borders, the Nigerian government states that they have also made attempts to control the spread of disease through an improvement in tracking, providing education to avert disinformation and increase accurate information, and the teaching of appropriate hygiene measures.

On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh was posthumously praised for preventing the index case (Sawyer) from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.

On 19 August, the Commissioner of Health in Lagos announced that Nigeria had seen twelve confirmed cases; four died (including the index case) while another five, including two doctors and a nurse, were declared disease-free and released. On 22 September, the Nigeria health ministry announced "As of today, there is no case of Ebola in Nigeria. All listed contacts who were under surveillance have been followed up for 21 days." The WHO stated that Nigeria had not reported any new cases since 8 September and if no further cases are reported, Nigeria will be declared Ebola-free on 20 October.

Countries with an initial case or cases

Senegal

In March, the Senegal Ministry of Interior closed the southern border with Guinea, but on 29 August the Senegal health minister announced Senegal's first case, a university student from Guinea who was being treated in Dakar. The WHO was informed on 30 August. According to the WHO, the case was a native of Guinea who had traveled by road to Dakar, arriving on 20 August. On 23 August, he sought medical care for symptoms including fever, diarrhoea, and vomiting. He received treatment for malaria, but did not improve and left the facility. Still experiencing the same symptoms, on 26 August he was referred to a specialized facility for infectious diseases, and was subsequently hospitalized.

On 27 August, authorities in Guinea issued an alert informing medical services in Guinea and neighbouring countries that a person who had been in close contact with an Ebola infected patient had escaped their surveillance system. The alert prompted testing for Ebola at the Dakar laboratory, and the positive result launched an investigation and triggered urgent contact tracing. On 10 September, it was reported that the student had recovered but health officials would continue to monitor his contacts for 21 days. On 22 September, the WHO announced that all contacts had completed the 21-day follow-up with no further cases of Ebola in Senegal.

Countries with medically evacuated cases

A number of healthcare workers who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in their country of origin.

France

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. She is being treated at a military hospital. Health Minister Marisol Touraine stated the nurse will receive an experimental drug.

Germany

Germany set up an isolation ward to care for six patients at the University Medical Center Hamburg-Eppendorf. On 27 August, a Senegalese epidemiologist working for the WHO in Sierra Leone became the first patient.

Spain

On 5 August, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares had been infected. He was volunteering in Liberia. The Spanish military helped with his transfer on 6 August 2014. Authorities stated he would be treated in the 'Carlos III' hospital in Madrid. This attracted controversy, amid questions as to the authorities' ability to guarantee no risk of transmission. Brother Pajares died from the virus on 12 August.

On 21 September the Spanish Ministry of Health released a press statement stating that Brother Manuel Garcia Viejo was evacuated to Spain from Sierra Leone. Brother Viejo, a medical director at the San Juan de Dios Hospital in Lunsar, Sierra Leone, is the second Spanish health worker to be infected with the disease. On Thursday 25 September the Spanish Ministry of Health announced the death of Brother Manuel Garcia Viejo in Madrid. Brother Viejo passed away after being infected with the virus in Sierra Leone.

Switzerland

On Monday 22 September a Swiss health worker was flown by a private airline to Geneva. The nurse was bitten by an Ebola-infected child on Saturday, 20 September in Sierra Leone. The unidentified male nurse will remain in isolation for 21 days at Geneva's University Hospital. The health ministry says it is unlikely that he was infected, but are monitoring him as a potential Ebola patient until the incubation period has passed.

United Kingdom

An isolation unit at the Royal Free Hospital received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone. He was released on September the 3rd.

United States

Kent Brantly, a physician and medical director in Liberia for the aid group Samaritan’s Purse, and co-worker Nancy Writebol were infected while working in Monrovia. Both were flown to the United States at the beginning of August for further treatment in Atlanta's Emory University Hospital. On 21 August, Brantly and Writebol recovered and were discharged.

On 4 September, a Boston physician, Rick Sacra, was airlifted from Liberia to be treated in Omaha at the Nebraska Medical Center. Working for Serving In Mission (SIM), he is the third US missionary to contract EVD. He believes he probably contracted Ebola while performing a caesarean section on a patient who had not been diagnosed with the disease. While in hospital, Sacra received a blood transfusion from Kent Brantly, who had recently recovered from the disease. On 25 September, Sacra was declared Ebola free and released from hospital.

On 9 September, the fourth U.S. citizen who contracted the Ebola virus arrived at Emory University Hospital in Atlanta for treatment. The identity of the patient, a doctor working for the WHO in Sierra Leone, was not released. He was scheduled to receive a blood or serum transfusion from a British man who had recently recovered from the disease. In addition, on 21 September, a CDC employee was flown back to the US after low risk exposure with a healthcare worker. Currently he shows no symptoms and is being monitored. The CDC announced he poses no risks to his family or the US.

Unrelated Ebola virus outbreak in Democratic Republic of the Congo

Democratic Republic of Congo-2014

DRC Ebola area as of 6 September 2014
Casualties
Cases / Deaths (as of 23 September 2014)  DR Congo: 70 / 42

An outbreak of Ebola Virus in the Democratic Republic of the Congo was reported in August 2014. The index case and the 80 contacts had no history of travel to the Ebola-affected countries or history of contact with individuals from the affected areas. By 18 August, 13 people, including three health care workers, were reported to have died of Ebola-like symptoms in the remote northern Équateur province, a province that lies about 750 miles north of the capital Kinshasa.

The WHO confirmed that the current strain of the virus in the Boende District is the Zaire Ebola species. This strain is common in the country and similar to the 1995 Kikwit outbreak in the Democratic Republic of Congo. The virology results and epidemiological findings indicated no connection to the current epidemic in West Africa Region or Nigeria.

On 26 August, the Équateur Province Ministry of Health confirmed an outbreak of Ebola to the WHO. The initial case was a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed. She was treated in a private clinic, but on 11 August she died of a then-unidentified hemorrhagic fever. The following week, relatives of the woman, several health-care workers who had treated the woman, and individuals with whom they had been in contact came down with similar symptoms. Five health care workers subsequently died.

On 2 September, the WHO said that there were currently 31 deaths in the Northern Boende area in the province of Équateur and 53 confirmed, suspected or likely cases.

On 9 September, the WHO raised the number of cases to 62 and the death toll to 35 from possible or confirmed Ebola cases. Included in this number are 9 health-care workers with 7 deaths among them. In total 386 contacts have been listed and 239 contacts are being followed up. The outbreak is still contained in Jeera county in the Boende region.

On 23 September, the WHO confirmed the number of cases at 70 and the death toll at 42 from possible or confirmed Ebola cases. Among this group are 8 health care workers.

Virology

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus (see graphic). Of the four disease-causing viruses, Ebola virus (formerly and often still called the Zaire virus), is the most dangerous and is the strain responsible for the ongoing epidemic in West Africa.

Since the discovery of the virus in 1976, Ebola disease has been confined to areas in Central Africa and it was initially thought that the current outbreak may be caused by a new strain rather than being imported from central to West Africa. However, further studies showed that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa into Guinea and West Africa in recent decades, rather than representing the emergence of a divergent and endemic virus.

In a study done by the Broad Institute and Harvard University, in partnership with the Sierra Leone Ministry of Health and Sanitation, researchers may have provided information about the origin and transmission of the Ebola virus that sets this outbreak apart from previous outbreaks. For this study, 99 Ebola virus genomes were collected and sequenced from 78 patients diagnosed with the Ebola virus during the first 24 days of the outbreak in Sierra Leone. The team found more than 300 genetic changes that make the 2014 Ebola virus distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current outbreak. Five members of the research team became ill and died from Ebola before the study was published in August.

Prevention

Ebolavirus outbreaks are controlled by infection control and containment, quarantine, and contact tracing.

Contact tracing

Contact tracing is an essential method to tamp down the spread of the disease. It involves finding everyone who had close contact with an Ebola case, and tracking them for 21 days. However, this requires careful record keeping by properly trained and equipped staff. WHO Assistant Director-General for Global Health Security, Keiji Fukuda, said on 3 September, "We don’t have enough health workers, doctors, nurses, drivers, and contact tracers to handle the increasing number of cases." This is a massive ongoing effort to volunteers and health workers. According to reports, 12,315 from Sierra Leone and 11,911 from Liberia are listed and being traced as at 23 September. Figures for Guinea are not known.

Travel restrictions and quarantines

Difficulties faced in attempting to contain the outbreak include the outbreak's multiple locations across country borders, Dr Peter Piot, the scientist who co-discovered the Ebola virus, has stated that the present outbreak is not following its usual linear patterns as mapped out in previous outbreaks. This time the virus is "hopping" all over the West African epidemic region. Furthermore, past epidemics have occurred in remote regions, but this outbreak has spread to large urban areas which has increased the number of contacts an infected person may have and has also made transmission harder to track and break.

On 8 August, a cordon sanitaire, a disease fighting practice that forcibly isolates affected regions, was established in the triangular area where Guinea, Liberia, and Sierra Leone are separated only by porous borders and where 70 percent of the known cases had been found. By September, the closure of borders had caused a collapse of cross-border trade and was having a devastating effect on the economies of the involved countries. A United Nations spokesperson reported that the price of some food staples had increased by as much as 150% and warned that if they continue to rise widespread food shortages can be expected.

On 2 September, WHO Director-General Margaret Chan advised against travel restrictions saying that they are not justified and that they are preventing medical experts from entering the affected areas and "marginalizing the affected population and potentially worsening ". UN officials working on the ground have also criticized the travel restrictions saying the solution is "not in travel restrictions but in ensuring that effective preventive and curative health measures are put in place." Médecins Sans Frontières, also speaking out against the closure of international borders, called it "another layer of collective irresponsibility": "The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be. A functional system of medical evacuation has to be set up urgently."

Infection control and containment efforts

Infection control and containment involves efforts in healthcare settings and in the community.

The Ebola virus can be eliminated with heat (heating for 30 to 60 minutes at 60 °C or boiling for 5 minutes). On surfaces, some lipid solvents such as some alcohol-based products, detergents, sodium hypochlorite (bleach) or calcium hypochlorite (bleaching powder), and other suitable disinfectants at appropriate concentrations can be used as disinfectants.

However, local and international authorities have struggled to contain the West Africa outbreak and there has been fierce criticism of the lack of attention and resources provided by the worldwide community.

Comparing the present Ebola outbreak to some in the past, the WHO notes that many of the most recent districts in which epidemics have occurred were in remote areas where the transmission had been easier to track and break. This outbreak is different in that large cities have been affected as well, where tracking has been difficult and medical staff may not suspect Ebola disease when they make a diagnosis. Several infectious diseases endemic to West Africa, such as malaria and typhoid fever, mimic the symptoms of Ebola disease, and doctors and nurses may see no need to take protective measures. Also, without recent past experience with the disease, people have become intensely fearful and have, in some cases, attacked medical staff, believing that they cause the disease.

Healthcare settings

The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include isolating them, sterilizing equipment and surfaces, and wearing protective clothing including masks, gloves, gowns, and goggles. If a person with Ebola dies, direct contact with the body of the deceased patient should be avoided.

Local authorities have not had resources to contain the disease. In late June, the Director-General of Médecins Sans Frontières said, "Countries affected to date simply do not have the capacity to manage an outbreak of this size and complexity on their own. I urge the international community to provide this support on the most urgent basis possible." Adequate equipment has not been provided for medical personnel, with even a lack of soap and water for hand-washing and disinfection.

Various aid organisations and international bodies, including the Economic Community of West African States (ECOWAS), the U.S. CDC and the European Commission have donated funds and mobilised personnel to help counter the outbreak; charities including Médecins Sans Frontières, the Red Cross, and Samaritan's Purse are also working in the area.

The outbreak was formally designated as a public health emergency of international concern on 8 August. This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) and invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.

Deaths of healthcare workers

Healthcare providers caring for people with Ebola and family and friends in close contact with people with Ebola are at the highest risk of getting infected because they may come in direct contact with the blood or body fluids of the sick person. In some places affected by the current outbreak, care may be provided in clinics with limited resources (for example, no running water, no climate control, no floors, and inadequate medical supplies), and workers could be in those areas for several hours with a number of Ebola infected patients. According to the WHO, the high proportion of infected medical staff can be explained by lack of the number of medical staff needed to manage such a large outbreak, shortages of protective equipment, or improperly using what is available, and "the compassion that causes medical staff to work in isolation wards far beyond the number of hours recommended as safe.".

At the end of August, the WHO reported that the loss of so many health workers was making it difficult for them to provide sufficient numbers of foreign medical staff, and the African Union launched an urgent initiative to recruit more health care workers from among its members.

The WHO reports that in the hardest hit areas there have historically been only one or two doctors available to treat 100,000 people, and these doctors are heavily concentrated in urban areas. The loss of so many health workers has made it difficult for the WHO to provide sufficient numbers of medical staff. Among the fatalities is Samuel Brisbane, a former advisor to the Liberian Ministry of Health and Social Welfare, described as "one of Liberia's most high-profile doctors."

In July, leading Ebola doctor Sheik Umar Khan from Sierra Leone died in the outbreak. His death was followed by two more deaths in Sierra Leone: Modupe Cole, a senior physician at the country`s main referral facility, and Sahr Rogers, who worked in Kenema. The African Union has launched an urgent initiative to recruit more health care workers from among its members.

Two American health workers who had contracted the disease in Liberia and later recovered said that their team of workers had been following "to the letter all of the protocols for safety that were developed by the CDC and WHO", including a full body coverall, several layers of gloves, and face protection including goggles. One of the two, a physician, had worked with patients, but the other was working to help workers get in and out of their protective gear, while wearing protective gear herself. In an interview she stated, "At this time we have not been able to confirm 100 percent the method of contagion. We are working closely with CDC and WHO to investigate. It is just an incredibly contagious disease."

In August, it was reported that healthcare workers had represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in an area which already faces a severe shortage of doctors. In August, the WHO reported that more than 240 health care workers had developed the disease and more than 120 had died; by 14 September, the cases had risen to 318 with 151 deaths. By 23 September, the WHO reported 378 workers had been infected and 211 had died. Liberia has been especially hard hit with almost half the total cases (184 with 89 deaths) reported. Sierra Leone registered 113 cases with 82 fatalities, thus indicating a death toll of seven out of ten. Guinea reported 67 infected cases with 35 deaths. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded.

Community

In order to reduce the spread, the World Health Organization recommends raising community awareness of the risk factors for Ebola infection and the protective measures individuals can take. These include avoiding contact with infected people and regular hand washing using soap and water. Traditional burial rituals, especially those requiring washing or embalming of bodies, have been discouraged. Airline crews are instructed to isolate anyone who has symptoms resembling Ebola virus.

A condition of dire poverty exists in many of the areas that have experienced a high incidence of infections. According to the director of the NGO Plan International in Guinea, "The poor living conditions and lack of water and sanitation in most districts of Conakry pose a serious risk that the epidemic escalates into a crisis. People do not think to wash their hands when they do not have enough water to drink."

Containment efforts have been hindered because there is reluctance among residents of rural areas to recognize the danger of infection related to person-to-person spread of disease, such as burial practices which include washing of the body of one who has died. A 2014 study found that nearly two thirds of cases of Ebola in Guinea are believed to be due to burial practices.

Denial in some affected countries has often made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus. There are reports that some people believe that the disease is caused by sorcery and that doctors are killing patients. In late July, the former Liberian health minister, Peter Coleman, stated that "people don't seem to believe anything the government now says."

Acting on a rumor that the virus was invented to conceal "cannibalistic rituals" (due to medical workers preventing families from viewing the dead), demonstrations were staged outside of the main hospital treating Ebola patients in Kenema, Sierra Leone. The demonstrations were broken up by the police and resulted in the need to use armed guards at the hospital. In Liberia, a mob attacked an Ebola isolation centre stealing equipment and "freeing" patients while shouting, "There's no Ebola." Red Cross staff were forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In the town of Womey in Guinea, at least eight aid workers were murdered by suspicious inhabitants with machetes and their bodies dumped in a latrine on September 18.

Criticism of containment efforts

Disease reports accelerated in August with 40% of the total cases reported in a period of only three weeks. The WHO stated that the acceleration could see the number of cases reported exceed 20,000.

Speaking at a United Nations (UN) briefing on 2 September, Joanne Liu, international president of Médecins Sans Frontières, criticized the lack of assistance from UN member countries.

"Six months into the worst Ebola epidemic in history, the world is losing the battle to contain it. In West Africa, cases and deaths continue to surge. Riots are breaking out. Isolation centers are overwhelmed. Health workers on the front lines are becoming infected and are dying in shocking numbers. Others have fled in fear, leaving people without care for even the most common illnesses. Entire health systems have crumbled. Ebola treatment centers are reduced to places where people go to die alone, where little more than palliative care is offered. It is impossible to keep up with the sheer number of infected people pouring into facilities. In Sierra Leone, infectious bodies are rotting in the streets."

Speaking in September after visiting Liberia, Sierra Leone, and Guinea, Tom Frieden, director of the U.S. CDC, said, "There is a window of opportunity to tamp this down, but that window is closing ... we need action now to scale up the response." On 16 September, United States President Barack Obama announced that the U.S. military will take the lead in overseeing the response to the epidemic. However the CDC has warned that there may be insufficient staff for the new treatment facilities which the international community is building.

Treatment

No proven Ebola virus-specific treatment exists as of August 2014. Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections. Early treatment may increase the chance of survival. Semen and possibly other body fluids (e.g. breast milk) may be infectious in survivors for months. Therefore it is advised to refrain from exchanging body fluids for at least 3 months.

Level of care

In late August, Médecins Sans Frontières (MSF) called the situation "chaotic" and the medical response "inadequate". They reported that they had expanded their operations but were unable to keep up with the rapidly increasing need for assistance which had forced them to reduce the level of care they were able to offer: "It is not currently possible, for example, to administer intravenous treatments." Calling the situation "an emergency within the emergency", MSF reported that many hospitals have had to shut down due to lack of staff or fears of the virus among patients and staff which has left people with other health problems without any care at all. Speaking from a remote region, a MSF worker said that a shortage of protective equipment was making the medical management of the disease difficult and that they had limited capacity to safely bury bodies.

By September, treatment for Ebola patients had become unavailable in some areas. Speaking on 12 September, WHO director-general Margaret Chan said, "In the three hardest hit countries, Guinea, Liberia and Sierra Leone, the number of new cases is moving far faster than the capacity to manage them in the Ebola-specific treatment centers. Today, there is not one single bed available for the treatment of an Ebola patient in the entire country of Liberia." According to a WHO report released on 19 September, Sierra Leone is currently meeting only 25% of its need for patient beds, and Liberia and Guinea are meeting only 20% of their needs.

Experimental treatments

The unavailability of treatments in the most-affected regions has spurred controversy, with some calling for experimental drugs to be made more widely available in Africa on a humanitarian basis, and others warning that making unproven drugs widely available would be unethical, especially in light of past experimentation conducted in developing countries by Western drug companies. As a result of the controversy, on 12 August an expert panel of the WHO endorsed the use of interventions with as-yet-unknown effects for both treatment and prevention of Ebola, and also said that deciding which treatments should be used and how to distribute them equitably were matters that needed further discussion.

Subsequently the WHO assistant director-general for health systems and innovation said on 5 September that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented immediately on a large scale in West Africa, although there is little information on the efficacy of such treatment. In mid-September the sale of black market blood from survivors of the disease has been noted as a new trend in the Ebola-affected regions. While serum derived blood from surviving victims has been used under strict control in certain cases, this trend in an uncontrolled manner could lead to other infectious diseases. This treatment must be properly implemented as a medical treatment under strict control and screening of possible donors. Margaret Chan of the WHO has criticized the use of this practice in a black market environment, noting concerns over "storage and collection methods".

A number of experimental treatments are being studied or will undergo trials proximately:

• ZMapp, a monoclonal antibody vaccine. The limited supply of the drug has been used to treat a small number of individuals infected with the Ebola virus. Although some of these have recovered the outcome is not considered statistically significant. ZMapp has proved highly effective in a trial involving rhesus macaque monkeys.
• TKM-Ebola, an RNA interference drug.
• Favipiravir, a drug approved in Japan for stockpiling against influenza pandemics. The drug appears to be useful in a mouse model of the disease and Japan has offered to supply the drug if requested by the WHO.
• In September, an experimental vaccine, currently known as the NIAID/GSK vaccine, commenced simultaneous Phase 1 trials in Oxford and Bethesda. The vaccine was developed jointly by GlaxoSmithKline and the NIH. If this phase is completed successfully, the vaccine will be fast tracked for use in West Africa. In preparation for this, GSK is preparing a stockpile of 10,000 doses.

Prognosis

According to a website for collaborative analysis and discussion about the Ebola emergence, as of 7 August, attempts to create an accurate Case Fatality Rate (CFR) had been unreliable due to differences in testing policies, the inclusion of probable and suspected cases, and primarily the rate of new cases that have not run their course. However, on 28 August, the WHO made their first overall case fatality rate estimate of 52%. It ranges from 42% in Sierra Leone to 66% in Guinea.

Compared to previous Zaire strain outbreaks, this number is quite low. The twelve Zaire strain outbreaks since the first one reported in the Democratic Republic of Congo in 1976 have had an average CFR of about 76%. Even the Sudan ebolavirus species, known to be less virulent than the Zaire species of the Ebola virus, has had an average CFR of about 57%. However, a weakness of the WHO figures is that they simply divide the number of deaths by the total number of total cases; this will underestimate the CFR as it includes recent diagnoses who may not survive. On 23 September, the WHO released a revised and far more accurate CFR of 70%, derived using data from patients with definitive clinical outcomes.

Projections of future cases

The basic reproduction number is a statistical measure of the number of people who are expected to be infected by one person who has the disease in question. If the rate is less than 1, the infection will die out in the long run and if the rate is greater than 1 the infection will continue to spread in a population. Using data supplied by the WHO, several studies done in early to mid September estimated a reproduction number of the EVD epidemic in West Africa between 1.2 and 2.5, with variations between countries and time during the outbreak.

A more recent study published on 23 September in the New England Journal of Medicine found that, "On the basis of the initial periods of exponential growth, the estimated basic reproduction numbers (R₀ ) are 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. The estimated current reproduction numbers (R) are 1.81 (95% CI, 1.60 to 2.03) for Guinea, 1.51 (95% CI, 1.41 to 1.60) for Liberia, and 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone; the corresponding doubling times are 15.7 days (95% CI, 12.9 to 20.3) for Guinea, 23.6 days (95% CI, 20.2 to 28.2) for Liberia, and 30.2 days (95% CI, 23.6 to 42.3) for Sierra Leone."

On 28 August, the WHO released its first estimate of the possible total cases (20,000) from the outbreak as part of its roadmap for stopping the transmission of the virus. The WHO roadmap states "his Roadmap assumes that in many areas of intense transmission the actual number of cases may be two- to fourfold higher than that currently reported. It acknowledges that the aggregate case load of EVD could exceed 20,000 over the course of this emergency. The Roadmap assumes that a rapid escalation of the complementary strategies in intense transmission, resource-constrained areas will allow the comprehensive application of more standard containment strategies within 3 months." It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.

When the WHO released its first estimated projected number of cases, a number of epidemiologists presented data to show that the WHO's projection of a total of 20,000 cases was likely an underestimate. On August 31, the journal Science quoted Christian Althaus, a mathematical epidemiologist at the University of Bern in Switzerland, as saying that if the epidemic were to continue in this way until December, the cumulative number of cases would exceed 100,000 in Liberia alone. According to a research paper released in early September, in the hypothetical worst-case scenario, if a reproduction number of over 1.0 continues for the remainder of the year we would expect to observe a total of 77,181 to 277,124 additional cases within 2014.

Writing in the NYT on 12 September, Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech, said that researchers at various universities who have been using computer models to track the growth rate say that at the virus’s present rate of growth, there could easily be close to 20,000 cases in one month, not in nine. On 3 September, Thomas Kenyon, Director of the U.S. CDC's Center for Global Health, said, "The highly virulent disease, which has claimed more than 1,900 lives so far, is spreading faster than health workers in Guinea, Liberia, Nigeria and Sierra Leone can manage."

Similar comments were made by Anthony Fauci, Director of the US NIH's National Institute of Allergy and Infectious Diseases, who said that 42 percent of the cases have occurred in the last month and that the outbreak is "completely out of control". He further noted that the rate of infection is exponential, saying "The number of cases per unit time is dramatically increasing." On 8 September, the WHO warned that the number of new cases in Liberia was increasing exponentially, and would increase by "many thousands" in the following three weeks. On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine controversially announced that the containment fight in Sierra Leone and Liberia has already been "lost" and that the disease will "burn itself out".

In a 23 September WHO report, the WHO revised their previous projection, stating that they expect there to be an excess of 20,000 Ebola cases in West Africa by 2 November. They further stated, that if the disease is not adequately contained it could become endemic in Guinea, Sierra Leone and Liberia, "spreading as routinely as malaria or the flu", and according to an editorial in the New England Journal of Medicine, eventually to other parts of Africa and beyond.

In a 23 September CDC report, a projection calculates a potential underreporting which is corrected by a factor of 2.5. With this correction factor, approximately 21,000 total cases are the estimate for the end of September 2014 in Liberia and Sierra Leone alone. The same report predicted that total cases, including unreported cases, could reach 1.4 million in Liberia and Sierra Leone by 20 January 2015 if no improvement in intervention or community behaviour occurred.

Economic effects

In addition to the loss of life, the outbreak is having a number of significant economic impacts.

• Markets and shops are closing, due to travel restrictions, cordon sanitaire, or fear of human contact, leading to loss of income for producers and traders.
• Movement of people away from affected areas has disturbed agricultural activities. The U.N. Food and Agriculture Organisation (FAO) has warned that the outbreak could endanger harvest and food security in West Africa.
• Tourism is directly impacted in affected countries. Other countries in Africa which are not directly affected by the virus have also reported adverse effects on tourism.
• Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.
• Many airlines have experienced reduced traffic. Some airlines have suspended flights to the area.
• Forecasts of economic growth have been reduced. A 4 August World Bank-IMF assessment for Guinea projected a full percentage point fall in GDP growth from 4.5 percent to 3.5 percent and on 17 September, they reported that if the epidemic continues to grow, the affected countries could see the economic impact grow eight-fold, "dealing a potentially catastrophic blow to the already fragile states."
• The outbreak is straining the finances of governments, with Sierra Leone using Treasury bills to fund the fight against the virus.
• The IMF is considering expanding assistance to Guinea, Sierra Leone, and Liberia as their national deficits balloon and their economies contract sharply.

Responses

International organizations

World Health Organization

In July, the World Health Organization (WHO) convened an emergency sub-regional meeting with health ministers from eleven countries in Accra, Ghana. On 3 July, the West African states announced collaboration on a new strategy, and the creation of a WHO sub-regional centre in Guinea "to co-ordinate technical support"; the centre was inaugurated in Conakry on 24 July.

The WHO Regional Director for Africa, Luis Sambo, visited the affected countries from 21 to 25 July, meeting with political leaders, ministers of health, NGOs, and other agencies. He stressed the need to "promote behavioural change while respecting cultural practices." On 24 July, WHO's Director General met with agencies and donors in Geneva to facilitate an increase in funding and manpower to respond to the outbreak. On 31 July, the WHO and West Africa nations announced a requirement for $100 million in aid to help contain the disease.

WHO declared the outbreak an international public health emergency on 8 August, after a two-day teleconference of experts. On 11 August, they emphasised lack of supplies and capacity as one of the problems, while local awareness of the disease had increased. Revised guidelines on how to prevent the spread of the disease were released, updating guidelines from 2008.

On 28 August, the WHO published a roadmap to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months. It simultaneously revised its cost estimate for the global resources required over the next six months up to $490 million. They report that they "are on the ground establishing Ebola treatment centres and strengthening capacity for laboratory testing, contact tracing, social mobilization, safe burials, and non-Ebola health care" and "continue to monitor for reports of rumoured or suspected cases from countries around the world." Other than cases where individuals are suspected or have been confirmed of being infected with Ebola, or have had contact with cases of Ebola, the WHO does not recommend any travel or trade restrictions.

On 16 September, the WHO Assistant Director General, Bruce Aylward, announced that the cost for combating the epidemic will be a minimum of $1 billion. "We don't know where the numbers are going on this," according to Aylward.

United Nations Security Council

On 18 September, the United Nations Security Council declared the Ebola virus outbreak in West Africa a "threat to international peace and security". The Security Council unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak. The resolution was the first in the history of the Security Council to deal with a public health crisis. It was sponsored by 131 countries, which – according to US Ambassador to the United Nations Samantha Power – makes it the most broadly supported of the 2,176 resolutions in the entire history of the United Nations.

For the first time in the history of the UN Security Council they have created a mission for a public health emergency. The United Nations Mission for Ebola Emergency Response (UNMEER) will be formed in the coming days. The mission's primary task will be coordinating the UN agencies' vast resources to combat the epidemic under the leadership of the WHO. In a press statement Dr. David Nabarro, the UN Secretary General’s Senior Coordinator, said, "This unprecedented outbreak requires an unprecedented response. The number of cases have doubled in these countries in the last three weeks. To get in front of this, the response must be increased 20-fold from where it is today." The city of Accra, in Ghana, will serve as a base for UNMEER from where they will work closely with the governments of the affected areas.

Médecins Sans Frontières

According to a WHO report released on 18 September, the humanitarian aid organisation Médecins Sans Frontières (Doctors Without Borders) is the leading organization responding to the crisis. Currently it has five treatment centers in the area with two in Guinea, two in Liberia and one in Sierra Leone. The centers are staffed by 210 international workers in collaboration with 1,650 staff from the affected regions.

Médecins Sans Frontières has campaigned since the beginning of the epidemic for a better response from governments and international agencies.

Economic Community of West African States

In March, the Economic Community of West African States (ECOWAS) disbursed US$250,000 to deal with the outbreak. In response to the ECOWAS Special Fund for the Fight Against Ebola, in July the Nigerian government donated 3.5 million dollars to Liberia, Guinea, Sierra Leone, the West African Health Organization, and the ECOWAS Pool Fund, to aid in the fight against the epidemic.

European Union

In April, a mobile laboratory, capable of performing the molecular diagnosis of viral pathogens of risk groups 3 and 4, was deployed in Guinea by the European Mobile Laboratory project (EMLab) as part of the WHO/GOARN outbreak response. Prior samples were analyzed at the Jean Mérieux BSL-4 Laboratory in Lyon.

World Bank Group

The World Bank Group has pledged US $230 million in emergency funding to help Guinea, Liberia, and Sierra Leone contain the spread of Ebola infections, help their communities cope with the economic impact of the crisis, and improve public health systems throughout West Africa. On 25 September The World Bank made additional funding of $170 million available to help curtail the spread of the Ebola virus. The funds will be used to finance medical supplies and increase the number of healthcare workers.

World Food Programme

On 18 August, the World Food Programme (WFP) of the United Nations announced plans to mobilize food assistance for an estimated 1 million people living in restricted access areas. In a 18 September WHO Ebola Response Roadmap Situation Report it was reported that as of that date the WFP have delivered an estimated 3,000 metric tonnes of food to the worst affected areas, enough to feed 147,500 people. They have also assisted in the transportation of 400 cubic meters of medical cargo.

National responses

A number of governments across the world have put measures in place to protect their populations from Ebola. These include:

• Advisory notices to warn travellers of the potential risk of travel to countries affected by the epidemic. (Germany, Spain, UK, USA, Colombia, Philippines, Saudi Arabia.)

• Withholding visitor visas from nationals of the affected countries, closing borders and cancelling flights. (Equatorial Guinea, Kenya, Sri Lanka, Nigeria, South Africa, Chad, Seychelles, Mauritania)

• Precautions such as isolation facilities, training of staff, biocontainment exercises, and health screening for incoming travellers. (Malta, Colombia, India, South Africa, Morocco, Mali, Germany, Philippines, Mauritania)

Australia

Australia announced on 17 September that it will commit an additional 7 million Australian dollars to help the international response to the Ebola outbreak in West Africa, bringing the total committed to AU$8 million. The funds will be divided between support to the British government's response, the World Health Organization, and Medecins Sans Frontieres. However MSF has declined the donation, saying that what's needed instead is a specialised deployment of civil and military assets.

Brazil

In response to the request for international cooperation made by the World Health Organization, Brazil's Health Ministry has donated a number of medical kits to affected countries. Each kit comprises 1.2 tons of supplies including antibiotics, anti-inflammatories, gloves and masks, sufficient to treat 500 patients for three months. Four kits have been allocated to Guinea, five to Sierra Leone and five more to Liberia.

Canada

On 12 August, the Public Health Agency of Canada (PHAC) announced that the country would donate between 800 and 1,000 doses of an untested vaccine (VSV-EBOV) to the WHO. The offer was made by the Minister of Health directly to the Director General of the WHO as part of the country's commitment to containment efforts. The Government of Canada holds the patent associated with the vaccine, but has licensed BioProtection Systems of Ames, Iowa to develop the product for use in humans.

As of 12 August, Canada's contribution to address the spread of the Ebola virus in West Africa is estimated at $5,195,000. This includes resources dedicated to humanitarian, security, and public health interventions.

On 6 September, the Public Health Agency of Canada announced that they will be resuming work at the Kailahun mobile laboratory in Sierra Leone after having recalled three members in late August, after they had possible contact with infected persons who had stayed in the same hotel. A team of three has been sent to the laboratory; staff will rotate on a monthly basis.

China

In August, China sent their second donation of supplies to Guinea, Sierra Leone, and Liberia. The supplies, worth 30 million yuan (4.9 million US dollars), include medical protective clothes, disinfectants, thermo-detectors, and medicines. China has also sent three expert teams composed of epidemiologists and specialists in disinfection and protection.

Some Chinese companies in West Africa have also joined the relief efforts. China Kingho Group, a leading exploration and mining company in Sierra Leone, donated 400 million leones (about $90,000) to the government and people of Sierra Leone on 15 August.

On 16 August, Chinese President Xi Jinping and UN Secretary-General Ban Ki-moon discussed several issues, including Ebola, in their fourth meeting this year. Xi said China will continue to make joint efforts with the international community to prevent and control the Ebola virus outbreak that has hit West Africa. China's medical teams in the countries are working with local staff, according to Xi. Xi also spoke highly of the measures taken by the United Nations and WHO and its professional institutions, and called for more assistance and input for medical and health services in African countries.On 25 September, a second mobile lab landed at Lungi Airport in Sierra Leone. The lab will assist the 29 CDC workers experts from China already in the region to help fight the disease.

Cuba

On 10 September, Cuba announced its willingness to help curtail the spread of the disease. Cuba will be sending 165 doctors and nurses to Sierra Leone on a six month rotation starting early October. Infection control specialists will be among the group. On 27 September, Cuba announced it is sending another 296 healthcare workers to the Liberia and Guinea. The first batch of 62 doctors and 103 nurses will be dispatched to Sierra Leone by October after they received the necessary training in tropical diseases.

Germany

The German government announced on 19 September that its contributions to the fight against Ebola had reached a total of euro 17 million to date. This includes contributions to the World Health Organisation, Medecins sans Frontieres, and other agencies. Material contributions include air transport to the region and a treatment station for Liberia.

On 22 September Ursula von der Leyen, the German defense minister, has asked volunteers from their military contingent to assist in staffing a clinic in the epidemic region. The minister appealed to soldiers to "voluntarily make yourselves available for this unusual mission."

Ghana

On 30 August, the Ghanaian Presidency released a press statement, announcing the country's willingness to use Accra as a support base to help fight Ebola in the stricken countries. This agreement follows a telephonic meeting with the United Nations chief, Ban Ki-moon and John Dramani Mahama, the President of Ghana. Accra will serve as a base for air lifting medical and other supplies to countries affected by the Ebola outbreak, as well as personnel to curtail the disease. In the coming months Ghana will play a major role in the fight against the disease in the region. The city of Accra will be the designated base for UNMEER, the newly formed mission by the UN.

Ivory Coast

The Ivory Coast, on 22 August, released a statement on state-owned television announcing the closure of its borders to the neighbouring countries affected by the Ebola outbreak. Attempting to prevent the Ebola outbreak of the virus from spreading to the Ivory Coast, the government announced the closure of all its land based borders to the country's West African neighbours Guinea and Liberia.

The Ivory Coast previously placed a ban on all flights to and from Sierra Leone, Liberia, and Guinea. Côte d'Ivoire (Ivory Coast) is allowing shipping commerce to enter the port of Abidjan from the affected countries of Guinea, Sierra Leone and Liberia. Vessels coming from those countries are required to undergo a medical inspection by a boarding team prior to entry.

Japan

In April, the Government of Japan gave $520,000 through the United Nations Children’s Fund (UNICEF) to support the Ebola outbreak response in Guinea. In August, another $1.5 million in additional support was provided to be disbursed via the WHO, UNICEF and Red Cross, and will be used for measures to prevent Ebola infections and to provide medical supplies.

On 25 August, Japanese authorities announced that they would be willing to provide access to an anti-influenza drug currently under development called favipiravir to try to treat EVD patients. Fujifilm Holdings Corp and MediVector have reportedly approached the U.S. Food and Drug Administration to request approval for this experimental use of favipiravir. Up to 20,000 doses of favipiravir would currently be available.

Malaysia

Malaysia plans to send more than 20 million medical gloves to Guinea, Liberia, Nigeria and Sierra Leone to alleviate a shortage of medical supplies in the affected countries. Malaysia will also send medical gloves to the Democratic Republic of Congo which is also dealing with an Ebola outbreak unrelated to the one affecting West Africa.

Philippines

The Department of Health expressed its willingness to send medical workers to Ebola-affected countries to help contain the outbreak. On 23 August, the Philippines announced that it is pulling out its 115 UN peacekeepers stationed in Liberia due to the increasing health risk the troops face due to the outbreak.

Saudi Arabia

In August, Saudi Arabia announced that it would block issuance of Hajj and Umrah visas to the citizens of Sierra Leone, Guinea, and Liberia.

United Kingdom

The UK government has made £2 million available to partners including the International Federation of the Red Cross (IFRC) and Médecins Sans Frontières that are operating in Sierra Leone and Liberia to tackle the outbreak. Additionally a £6.5 million rapid response research initiative has been announced jointly by the Department for International Development and the Wellcome Trust to better inform the management of Ebola outbreaks. This includes research which could help tackle the current outbreak.

On 8 September Mark Francois, a spokesperson for the Minister of Armed Forces, announced that British troops, medics and equipment will be deployed to help assist Sierra Leone in the containing of the disease. The troops will be building a 62 bed treatment facility near Freetown. The Armed Forces' engineers and medics expect the facility to be completed and operational in two months. The treatment center will be staffed by Armed Forces’ medical personnel and handed over to one of the aid organizations in the country.

United States

By the beginning of August, the Centers for Disease Control had placed staff in Guinea, Sierra Leone, Liberia, and Nigeria to assist the local Ministries of Health and WHO-led response to the outbreak. On 8 September, United States President Barack Obama announced that the United States government would send military personnel to the epidemic area. The military will assist in the setting up of isolation units, supplying transportation of medical equipment, and providing additional safety to health workers in the area. The announcement came amid fears that the virus might mutate and become more virulent and "represents a serious national security concern."

On 8 September, the Department of Defense announced that it had allocated $22 million to set up a 25-bed field hospital in Liberia to treat healthcare workers affected by the Ebola virus. On 9 September, the United States Agency for International Development (USAID) announced that it will support the African Union’s deployment of approximately 100 health workers to West Africa to manage and run Ebola treatment units.

On 16 September, President Obama announced that the U.S. military will take the lead in overseeing the response to the epidemic. The military will dispatch up to 3,000 personnel to West Africa in an effort that could cost up to $750 million over the next six months. The US forces will not be involved directly in treatment of patients, but will be involved in setting up treatment facilities and other logistical support. U.S. Major General Darryl A. Williams, Commander, United States Army Africa, will head a regional command based in Liberia that will help oversee and coordinate U.S. and international relief efforts while a new, separate regional staging base in Senegal will help accelerate transportation of urgently needed equipment, supplies and personnel. In addition, the Pentagon will send engineers to set up 17 treatment centers in Liberia — each with a 100-bed capacity — and will set up a site in the region to train up to 500 health-care workers a week.

Charitable organizations, foundations and individuals

Bill & Melinda Gates Foundation

On 10 September, the Bill & Melinda Gates Foundation released $50 million to the United Nations and other international aid agencies fighting the epidemic. The foundation also donated $2 million to the CDC to assist them with their burden. Previous donations consisted of $5 million to the WHO and $5 million to UNICEF to buy medical supplies and fund support efforts in the region. “We are working urgently with our partners to identify the most effective ways to help them save lives now and stop transmission of this deadly disease,” the Foundation CEO said in a statement.

Paul G. Allen Family Foundation

On 11 September, the Paul G. Allen Family Foundation pledged $9 million to the CDC. The funds will be appropriated to build treatment co-ordination centers and assist in training programs. This follows their earlier donation of $2.8 million, in August, to the Red Cross.

Samaritan's Purse

Samaritan's Purse is providing direct patient care in multiple locations in Liberia. At a congressional committee hearing on 7 August 2014, the head of Samaritan's Purse told the committee, "The international response has been a failure, and it's important to understand that."

Wellcome Trust

The Wellcome Trust announced on 23 September a £(British pounds) 3.2 million grant to fast-track trials of the most promising Ebola treatments. This will enable multiple partners around the world to quickly establish clinical trials at existing Ebola treatment centres in West Africa, where treatments can be formally evaluated in patients with Ebola virus disease.

Individual contributors

On 14 August, the Nigerian government said Aliko Dangote had donated $1 million to halt the spread of the Ebola virus outbreak.

Popular culture

"Ebola in Town", a dance tune by a group of West African rappers warning people of the dangers of the Ebola virus and explaining how to react, became popular in Guinea and Liberia during the first quarter of 2014.

In August 2014, George Weah and Ghanaian musician Sidney produced a song to raise awareness about Ebola.

There are a number of Ebola-themed jokes circulating in West Africa to spread awareness.

Timeline of reported cases and deaths

Data comes from reports by the Centers for Disease Control and Prevention and the WHO. All numbers are correlated with United Nations Office for the Coordination of Humanitarian Affairs (OCHA) if available. The table includes suspected cases that have not yet been confirmed. The reports are sourced from official information from the affected countries' health ministries. WHO has stated the reported numbers "vastly underestimate the magnitude of the outbreak", saying there may be 2.5 times as many cases as officially reported. Cases in remote areas may also be missed.

There is also evidence of under-reporting of deaths in Freetown, Sierra Leone. The Sierra Leone Ministry of Health and Sanitation reports only 12 deaths for the Western Area Urban District and Western Area Rural District that include Freetown, despite a report that, "in the last eight days alone, 110 Ebola victims have been buried at King Tom Cemetery" in Freetown, figures which were "based on medical certificates".

According to WHO this is also evident in Liberia where no new cases were reported in Monrovia in their latest releases by the Liberian government. Monrovia in previous epidemiological weeks reported a sharp daily rise in the capital. This is confirmed by "credible reports obtained from responders in Liberia." According to this source the situation is deteriorating in Liberia and in Monrovia there is evidence of this fact. The report also states that the cases uncovered from the three day lock-down (18 - 21 September) in Sierra Leone still need to be added to these latest figures.

The case numbers reported may include probable or suspected cases. Numbers are revised downward if a case is later found to be negative. (Numbers may differ from reports as per respective Government reports. See notes at the bottom for stated source file.)

• Cumulative totals of cases and deaths over time
• Cumulative totals in log scale
• Average new cases and deaths per day (between WHO reporting dates)

• Cumulative number of cases by country, using a linear scale.
• Cumulative number of cases by country, using a logarithmic scale.

Notes:

Date is the "as of" date from the reference. A single source may report statistics for multiple "as of" dates.

Total cases and deaths before 1 July 2014 are calculated.

Numbers with ± are deltas from a previous report. The deltas may not be consistent.

Numbers with a ↓ indicate cases that were eliminated.

Liberia:

29 Mar: LI data is confused. Earlier, there were 8 suspected cases and 6 deaths (no confirmed cases). Seven suspected cases were tested by 29 Mar, and five were not Ebola. That should take suspected cases to 3, but a total was not stated; it also implies deaths should be at most 3. The report states only 2 suspected deaths were tested, and one was not Ebola.

21 Apr: reduced deaths by 2: one in Guinea total and one case discarded. 26 samples negative for Ebola.

24 Apr: stated it was reviewing its 27 suspected cases and may toss all of them;

2 May: reclassification complete.

Sierra Leone: cases were reported, but by 3 May there were no cases. Early reports are marked with parens "()".

7 Apr: 2 suspected cases of EVD were confirmed as Lassa Fever.

15 Apr: Of 12 suspected cases, 11 were tested for Ebola but came up negative.

Mali: 4 possible cases were reported on 7 April, but they were not EVD.

1. 23 Sept Liberia, Guinea,Nigeria and Senegal as per WHO report. Modified with Sierra Leone death toll as per Gov which is lower than WHO death toll (605).
2. 21 Sept Liberia, Guinea as per WHO report. modified with Sierra Leone death toll as per Gov which is lower than WHO death toll (597)
3. 17 Sept Guinea and Senegal as per OCHA report. Updated with Liberia numbers as per Gov. Updated with Sierra Leone per Gov (OCHA report states 18 Sept but totals are as per SL gov on 17 Sept) Nigeria and Senegal stat.
4. 14 Sept Guinea as per WHO report. Updated with Liberia numbers as per Gov. Updated with Sierra Leone death toll as per Gov
5. 10 Sept From Primary Source OCHA and Liberia government. Nigeria and Senegal stat
6. 7 Sept WHO report Sierra Leone death rate suspected added up double in report.
7. 31 Aug WHO SL death toll wrong.

References

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External links

• Outbreak Updates, World Health Organization (WHO).
• Outbreak Updates, US Centers for Disease Control and Prevention (CDC).
• 2014 Ebola Outbreak Timeline Healthmap.org

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