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Western African Ebola epidemic

Situation map of the outbreak in West Africa
Date	December 2013 – present
Casualties
Reported Cases/Deaths Note: the CDC estimates that actual cases in Liberia, Sierra Leone, and Guinea are two to three times higher than officially reported numbers. Country Cases Deaths Last Update Liberia 6,878 2,812 10 November 2014 Sierra Leone 5,586 1,514 11 November 2014 Guinea 1,919 1,166 11 November 2014 Nigeria 20 8 outbreak ended 20 October 2014 Mali 6 5 14 November 2014 United States 4 1 11 November 2014 Senegal 1 0 outbreak ended 17 October 2014 Spain 1 0 11 November 2014 Total 14,415 5,506 As of 14 November 2014 See notes for 11 November on Timeline Section

As of 2014, the most widespread epidemic of Ebola virus disease (EVD) in history is currently ongoing in several West African countries. It has caused significant mortality, with a reported case fatality rate (CFR) of about 71%. It began in Guinea in December 2013 and then spread to Liberia and Sierra Leone. A small outbreak of twenty cases occurred in Nigeria and one case occurred in Senegal; both countries were declared disease-free on 20 October 2014. Several cases have been reported in Mali. Imported cases in the United States and Spain have led to secondary infections of medical workers but have not spread further. An independent outbreak of EVD in the Democratic Republic of the Congo that started in August 2014 has been shown by genetic analysis to be unconnected to the main epidemic.

As of 11 November 2014, the World Health Organization (WHO) and respective governments has reported a total of 14,413 suspected cases and 5,504 deaths, though the WHO believes that this substantially understates the magnitude of the outbreak with true figures numbering three times as many cases as have been reported. The assistant director-general of the WHO warned in mid-October that there could be as many as 10,000 new EVD cases per week by December 2014. Almost all of the cases have occurred in the three initial countries.

Some countries have encountered difficulties in their efforts to control the epidemic. In some areas, people have become suspicious of both the government and hospitals, some of which have been attacked by angry protesters who believe either that the disease is a hoax or that the hospitals are responsible for the disease. Many of the areas seriously affected by the outbreak are areas of extreme poverty with limited access to the soap and running water needed to help control the spread of disease. Other factors include reliance on traditional medicine and cultural practices that involve physical contact with the deceased, especially death customs such as washing the body of the deceased. Some hospitals lack basic supplies and are understaffed, increasing 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. In September, the WHO estimated that the countries' capacity for treating EVD patients was insufficient by the equivalent of 2,122 beds. By the end of October many of the hospitals in the affected area had become dysfunctional or had been closed, leading some health experts to state that the inability to treat other medical needs may be causing "an additional death toll likely to exceed that of the outbreak itself".

By September 2014, Médecins Sans Frontières/Doctors Without Borders (MSF), the NGO with the largest working presence in the affected countries, had grown increasingly critical of the international response. Speaking on 3 September, the president of MSF 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." On 3 September, the United Nations’ senior leadership said it could be possible to stop the Ebola outbreak 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". In a 26 September statement, the WHO said, "The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long."

Articles related to the
Western African Ebola virus epidemic
Overview
Ebola virus disease Timeline of the epidemic Responses to the epidemic Timeline, tables and graphs Ebola virus disease treatment research Post-Ebola virus syndrome Ebola vaccine
Nations with widespread cases
Guinea Liberia Sierra Leone
Other affected nations
Mali Nigeria Senegal Spain United States United Kingdom Italy
Other outbreaks
List of Ebola outbreaks 1976 Zaire Ebola virus outbreak 2014 DR Congo outbreak Kivu Ebola epidemic List of epidemics and pandemics
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Epidemiology

Outbreak

Researchers believe that a 2-year-old boy, later identified as Emile Ouamouno, who died in December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea, was the index case of the current Ebola virus disease epidemic. Reports suggest that his family hunted bats of the Ebola-harboring species Hypsignathus monstrosus and Epomops franqueti for bushmeat, which may have been the original source of the infection. His mother, sister, and grandmother then became ill with similar symptoms and also died. People infected by those initial cases 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 other 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." By 24 March, MSF had set up an isolation facility in Guéckédou.

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. By 31 March, there were 112 suspected and confirmed cases including 70 deaths, while two cases were reported from Liberia of people who had recently traveled to Guinea. On 30 April, Guinea's Ministry of Health reported 221 suspected and confirmed cases with 146 deaths, including 26 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 number of cases reported had reached 281 with 186 deaths.

In Liberia, the disease was reported in four counties by mid-April and cases in Liberia's capital Monrovia were reported in mid-June. The outbreak then spread to Sierra Leone and progressed rapidly. A study of the virus genomes determined that twelve Sierra Leone residents had become infected while attending a funeral in Guinea. 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. By 17 July, the total number of suspected cases in the country stood at 442, overtaking the number in Guinea and Liberia. By 20 July, additional cases of the disease had been reported in the Bo District and 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 effort to contain the disease, possible contacts were monitored – 353 in Lagos and 451 in Port Harcourt. On 22 September, the WHO reported a total of 20 cases, including eight deaths. The WHO's representative in Nigeria officially declared Nigeria Ebola-free on 20 October after no new active cases were reported in the follow up contacts.

On 29 August, Senegalese Minister of Health announced the first case in Senegal. The victim 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 person subsequently recovered, and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.

Two Spanish health care workers contracted Ebola and were transferred to Spain for treatment where they both died. In October, a nursing assistant who had been part of their health care team was diagnosed with Ebola, making this the first case of Ebola contracted outside of Africa. The nursing assistant recovered and was declared disease-free on 19 October. There have been cases of Ebola in the United States of America as well. A Liberian man who had traveled from Liberia to be with his family in Texas was declared to have Ebola and subsequently died on 8 October. Two nurses who had cared for the patient contracted the disease; both of the nurses have subsequently recovered and tested Ebola-free on 27 October 2014. On 23 October, the first case of Ebola disease in Mali was confirmed, a two year-old girl who had returned from Guinea, and two further cases were reported in November.

Countries with widespread transmission

Guinea

On 25 March, the World Health Organization (WHO) reported an outbreak of Ebola virus disease in four southeastern districts with a total of 86 suspected cases, including 59 deaths. MSF was helping the Ministry of Health of Guinea in establishing Ebola treatment centers in the epicenter of the outbreak. 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 as they led an international response to the Ebola outbreak.

Thinking that the virus was contained, MSF 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 19 October, Guinea reported two new districts with EVD cases. The Kankan district, on the border with the Côte d'Ivoire and a major trade route to Mali, confirmed 1 case. Kankan also borders the district of Kerouane in this country, one of the areas with the most intense virus transmissions. The Faranah district to the north of the border area of Koinadugu in Sierra Leone in the north also reported a confirmed case. Koinadugu was one of the last EVD free regions in that country. According to the latest WHO report this new development highlights the need for increased surveillance of cross border traffic in an effort to contain the disease to the three most affected countries.

Liberia

In Liberia, the disease was reported in Lofa and Nimba counties in late March. 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. Football events were banned, schools and universities were closed, and the worst-affected areas in the country were to be placed under quarantine. In August, Liberian forces fired indiscriminately at protesters that were against an Ebola quarantine in Monrovia. An inquiry into the incident found the security forces at fault, stating they "fired with complete disregard for human life”. On 4 August, the Liberian government ordered corpses of those that died from the Ebola virus disease to be cremated. Ebola corpses are highly contagious immediately after death.

With only 50 physicians in the entire country—one for every 70,000 Liberians—Liberia already faced a health crisis even before the outbreak. In September the US CDC reported that some hospitals had been abandoned while those which were still functioning lacked basic facilities such as running water, rubber gloves, and sanitizing supplies. In October, the Liberian ambassador in Washington was reported as saying that he feared that his country may be "close to collapse". By 24 October, all of the 15 Liberian districts had reported cases of Ebola.

On 29 October, the WHO announced that the rate of new infections in Liberia was declining, but urged continued vigilance against a reversal of this trend. On 10 November MSF announced that isolation units in some parts of the country now have adequate capacity. However hotspots of Ebola are expected to emerge in towns and villages in Liberia, and the international response should be modified to a flexible approach that allows a rapid response to new outbreaks and gets the regular healthcare system safely up and running again. On November 10th, the U.S. opened the first Ebola treatment facility, for Liberia, in Tubmanburg.

On Thursday 13 November the Liberian President, Ellen Johnson Sirleaf announced the lifting of the state of emergency in the country following the decrease in the number of new cases in the country.

Sierra Leone

The first person reported infected in the spread to Sierra Leone was a tribal healer. She had treated one or more infected people 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 neighbouring towns. On 11 June, Sierra Leone shut its borders for trade with Guinea and Liberia and closed some schools in an attempt to slow the spread of the virus. On 30 July, the government began to deploy troops to enforce quarantines. By 15 October, the last district in Sierra Leone untouched by the disease had declared Ebola cases.

On 1 November, it was reported the UK would begin building three new Ebola treatment centers; "there are just not enough testing facilities", according to one source. On November 2, the vast nature of the "under-reporting" was brought to light: "the situation is catastrophic. There are several villages and communities that have been basically wiped out. In one of the villages I went to, there were 40 inhabitants and 39 died", one source cited. On 4 November, it was reported that thousands violated quarantine in search for food, in the town of Kenema. On November 6, it was reported that the situation was "getting worse" due to "intense transmission" in Freetown as a contributing factor; the capital city reported 115 cases in the last week alone. Food shortages and aggressive quarantines are making the situation worse according to the Disaster Emergency Committee. On November 12th, more than 400 health workers went on strike at one of the few Ebola treatment centers in the country, over salary issues.

Countries with limited local transmission

Spain

On 5 August 2014, the Brothers Hospitallers of St. John of God confirmed that Brother Miguel Pajares, who had been volunteering in Liberia, had become infected. He was evacuated to Spain on 6 August, and died on 12 August. On 21 September it was announced that Brother Manuel García Viejo, another Spanish citizen who was medical director at the San Juan de Dios Hospital in Lunsar, had been evacuated to Spain from Sierra Leone after being infected with the virus. His death was announced on 25 September.

In October, a nursing assistant, later identified as Teresa Romero, who had cared for these patients became unwell and on 6 October tested positive for Ebola. A second test confirmed the diagnosis, making this the first confirmed case of Ebola transmission outside Africa. On 19 October, it was reported that Romero had recovered and was officially declared to be Ebola free.

United States

On 30 September, the United States Centers for Disease Control and Prevention (CDC) declared its first case of Ebola virus disease. The CDC disclosed that Thomas Eric Duncan became infected in Liberia and traveled to Texas on 20 September. On 26 September he fell ill and sought medical treatment but was sent home with antibiotics. He returned to the hospital by ambulance on 28 September and was placed in isolation and tested for Ebola. Thomas Duncan died on 8 October. On 19 October his four relatives and 44 other people who had had contact with Duncan were released from quarantine.

On 12 October, the CDC confirmed that a health worker who treated Duncan tested positive for the Ebola virus, making this the first known transmission of the disease in the United States. Two days later a second health worker at the same hospital tested positive for Ebola. Nina Pham, the first nurse infected, was transferred to a facility at the National Institutes of Health (NIH) in Bethesda, Maryland on 16 October, while the second, Amber Joy Vinson, was transferred to Emory University Hospital in Atlanta, Georgia. Both patients recovered and were declared free of the virus by 24 October. A fourth case of Ebola virus disease was diagnosed on 23 October in New York City. MSF doctor Craig Spencer had recently returned from treating Ebola patients in West Africa where he contracted the disease. On 11 November, Spencer was declared Ebola-free.

Mali

On 23 October, the first case of Ebola disease in Mali was confirmed in the town of Kayes; a two year-old girl who had arrived with a family group from Guinea. Her father had worked for the Red Cross in Guinea and had also worked in a private health clinic; he died earlier in the month, likely from an Ebola infection which he had contracted in the private clinic. It was later established that a number of family members had also died of Ebola. A family group returned to Mali after the father's funeral via public bus and taxi, a journey of more than 1200 kilometres. On 23 October, the girl tested positive for Ebola but died on the next day.

MSF dispatched a team to Mali late October to provide technical support to the Ministry of Health. As of 10 November, aid agencies have identified 108 contacts of the symptomatic patient, including 33 health care workers who were exposed. 25 of these have been followed for 21 days and have been released from the surveillance system.

Between 12 and 14 November Mali reported one definite and two probable deaths from Ebola, in an outbreak which is not connected with the first case in Kayes. The first probable case was an imam who had fallen ill on 17 October in Siguiri, Guinea and had transferred to the Pasteur Clinic in Bamako, Mali for treatment. He was treated for kidney failure but was not tested for Ebola; he died on 27 October. A friend who had visited him in hospital also died of an unidentified disease: retrospectively WHO has classified both as probably caused by Ebola. After the imam's death his body was washed according to Muslim tradition and returned Guinea for burial. Subsequent contact tracing has established that a number of the imam's family members in Guinea became infected with Ebola; however contact tracing has been hampered by the delay of two weeks since the imam passed away.

A nurse in Bamako who had treated the imam subsequently fell ill; on 11 November he tested positive for Ebola and died. On Thursday 13 November a doctor at the Pasteur Clinic tested positive for Ebola and is being treated. Additionally the Malian Health Ministry has announced that one of the women who helped wash the imam's body died on 13 November, and subsequently tested positive for Ebola. As a result over 200 more contacts are being traced over four locations in Mali.

Countries with contained spread

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 a Dakar hospital. The case was a native of Guinea who had traveled 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 28 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. No further cases were reported. and on 17 October, the WHO officially declared that the outbreak in Senegal had ended.

The WHO have officially commended the Senegalese government, and in particular the President Macky Sall and the Minister of Health Dr Awa Coll-Seck, for their quick response in quickly isolating the patient and tracing and following up 74 contacts as well as for their public awareness campaign. This acknowledgement was also extended to MSF and the CDC for their assistance.

Nigeria

The first case in Nigeria was a Liberian-American, Patrick Sawyer, who flew from Liberia to Nigeria's commercial 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 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 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." According to the WHO, 19 cases and 7 deaths had been confirmed, along with the imported case, who also died. Four of the dead were health care workers who had cared for Sawyer. In all, 529 contacts had been followed and of that date they had all completed a 21 day mandatory period of surveillance. The WHO's representative in Nigeria officially declared Nigeria to be Ebola free on 20 October after no new active cases were reported in the follow up contacts, stating it was a "spectacular success story".

On 9 October, the European Centre for Disease Prevention and Control (ECDC) acknowledged Nigeria's positive role in controlling the effort to contain the Ebola outbreak. "We wish to thank the Federal Ministry of Health, Abuja, Nigeria, and the staff of the Ebola Emergency Centre who coordinated the management of cases, containment of outbreaks and treatment protocols in Nigeria." Nigeria's quick responses, including intense and rapid contact tracing, surveillance of potential contacts, and isolation of all contacts were of particular importance in controlling and limiting the outbreak, according to the ECDC. Complimenting Nigeria's successful efforts to control the outbreak, "the usually measured WHO declared the feat 'a piece of world-class epidemiological detective work'."

Countries with medically evacuated cases

A number of people who had become infected with Ebola virus disease have been medically evacuated to treatment in isolation wards in Europe or the US. These are mostly health workers with one of the NGOs in the area.

France

A French volunteer health worker, working for MSF in Liberia, contracted EVD and was flown to France on 18 September. After successful treatment at Hospital Begin, a military hospital near Paris, she was discharged on 4 October.

On 1 November 2014, a United Nations employee suffering from Ebola was evacuated from Sierra Leone to France for treatment. The person, whose gender wasn’t disclosed, is not a French citizen.

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. On 4 October he was discharged after being declared noninfectious.

The WHO requested that a Ugandan doctor working in Sierra Leone who had contracted the disease be treated in Germany. The request was granted by Germany and he was flown to the country on 3 October. The patient is being treated in an isolation unit at the University Hospital in Frankfurt. The doctor was working for an Italian NGO in Sierra Leone, according to Stefan Gruettner, the State Health Minister of Hessen.

On 9 October, a third patient was medevaced to Leipzig, Germany. The 56-year-old Sudanese man, who worked as a UN employee in Liberia, was transferred to St Georg Hospital in Leipzig. He died on 14 October, becoming the first person on German soil to die of Ebola.

Norway

On 6 October, MSF announced that one of their workers, a Norwegian national, had become infected in Sierra Leone. On 7 October the woman, Silje Lehne Michalsen, was admitted to a special isolation unit at Oslo University Hospital. On 20 October, it was announced that she had been successfully treated and had been discharged. It was reported that Michalsen had received an unspecified drug as part of her treatment plan. After discharge Michalsen remarked, "For three months I saw the total absence of an international response. For three months I became more and more worried and frustrated."

United Kingdom

An isolation unit at the Royal Free Hospital, London, received its first case on 24 August. William Pooley, a British nurse, was evacuated from Sierra Leone by the Royal Air Force on a specially-equipped C-17 aircraft. He was released from hospital on 3 September.

United States

A number of American citizens who contracted Ebola virus disease while working in the affected areas have been evacuated to the United States for treatment; none have died.

Separate outbreak in the Democratic Republic of the Congo

In August 2014, the WHO reported an outbreak of Ebola virus in the Boende District, Democratic Republic of the Congo (DRC). They confirmed that the virus is of the Zaire Ebola species, which is common in the DRC ( "Zaire" is the former name of the DRC). The virology results and epidemiological findings indicate no connection to the current epidemic in West Africa. This is the country's seventh Ebola outbreak since 1976.

In August, 13 people were reported to have died of Ebola-like symptoms in the remote northern Équateur province. The initial case was reported to have been a woman from Ikanamongo Village who became ill with symptoms of Ebola after she had butchered a bush animal that her husband had killed, however more recent findings suggest that there may have been several previous cases and an investigation is ongoing. According to the WHO, as of 28 October 2014, there had been 66 cases with 49 deaths including eight healthcare workers. Twenty days had passed since the last reported case was discharged and no new contacts were being followed. After 42 days have passed the DRC can be declared Ebola free.(approx. 20 November 2014)

Virology

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

Since the discovery of the viruses in 1976 when outbreaks occurred in Sudan and the Democratic Republic of Congo (then called Zaire), Ebola virus disease has been confined to areas in Central Africa, where it is endemic. With the current outbreak, it was initially thought that a new species endemic to Guinea might be the cause, rather than being imported from central to West Africa. However, further studies have shown that the current outbreak is likely caused by an Ebola virus lineage that has spread from Central Africa into West Africa, with the first viral transfer to humans in Guinea.

In a study done by Tulane University, 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. From the resulting sequences, and three previously published sequences from Guinea, the team found 341 genetic changes that make the outbreak distinct from previous outbreaks. It is still unclear whether these differences are related to the severity of the current situation. Five members of the research team became ill and died from Ebola before the study was published in August.

Transmission

It is not entirely clear how an Ebola outbreak starts. The initial infection is believed to occur after an Ebola virus is transmitted to a human by contact with an infected animal's body fluids. Evidence strongly implicates bats as the reservoir hosts for ebolaviruses. Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and duikers feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations.

Human-to-human transmission occurs only via direct contact with blood or bodily fluids from an infected person who is showing signs of infection or by contact with objects recently contaminated by an actively ill infected person. Airborne transmission has not been documented during Ebola outbreaks. The time interval from infection with the virus to onset of symptoms is two to twenty-one days. Because dead bodies are still infectious, the handling of the bodies of Ebola victims can only be done while observing proper barrier/ separation procedures. Semen and possibly other body fluids (e.g., breast milk) may be infectious in survivors for months.

One of the primary reasons for spread is the poorly-functioning health systems in the part of Africa where the disease occurs. The risk of transmission is increased among those caring for people infected. Recommended measures when caring for those who are infected include medical isolation via the proper use of boots, gowns, gloves, masks and goggles, and sterilizing equipment and surfaces.

Even with proper isolation equipment available, working conditions such as no running water, no climate control, and no floors may continue to make direct care more difficult. Two American health workers who had contracted the disease and later recovered said that to the best of their knowledge 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 assisting workers to get in and out of their protective gear, while wearing protective gear herself. Successfully addressing one of the "biggest danger(s) of infection" faced by medical staff requires their learning how to properly suit up with, and later remove, personal protective equipment. In Sierra Leone, the typical training period for the use of such safety equipment lasts approximately 12 days.

Difficulties in attempting to contain the outbreak include its 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 made transmission harder to track and break.

Containment and control

On 28 August the WHO published a roadmap of the steps required to bring the epidemic under control and to prevent further transmission of the disease within West Africa; the coordinated international response is working to realise this plan. Key elements required to prevent transmission are contact tracing and follow-up as well as social mobilisation and public awareness.

Surveillance and contact tracing

Contact tracing is an essential method of preventing the spread of the disease. This requires effective community surveillance so that a possible case of Ebola can be registered and accurately diagnosed as soon as possible, and subsequently finding everyone who has had close contact with the 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." There is a massive ongoing effort to train volunteers and health workers, sponsored by USAID. According to reports, 20,419 people from Sierra Leone and 18,699 from Liberia are listed and being traced as of 17 October. Figures for Guinea are not known.

Community awareness

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. A condition of extreme 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."

A number of organisations have enrolled local people to conduct public awareness campaigns among the communities in West Africa. "...what we mean by social mobilization is to try to convey the right messages, in terms of prevention measures, adapted to the local context – adapted to the cultural practices in a specific area,” said Vincent Martin, FAO’s representative in Senegal.

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. An August 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 also made containment efforts difficult. Language barriers and the appearance of medical teams in protective suits has sometimes increased fears of the virus. 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. On 18 September in the town of Womey in Guinea, suspicious inhabitants wielding machetes murdered at least eight aid workers and dumped their bodies in a latrine.

Travel restrictions and quarantines

There is serious concern that the disease may spread further within West Africa or elsewhere in the world.

West Africa

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. This has subsequently been replaced by a series of simple checkpoints for hand-washing and measuring body temperature on major roads throughout the region, manned either by local volunteers or by military.

International

Many countries have considered imposing restrictions on travel to or from the region. On 2 September, WHO Director-General Margaret Chan advised against this, saying that they are not justified and that they are preventing medical experts from entering the affected areas and are "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". MSF, also speaking out against the closure of international borders, called it "another layer of collective irresponsibility" and added, "The international community must ensure that those who try to contain the outbreak can enter and leave the affected countries if need be."

In early August, airports in Guinea, Liberia and Sierra Leone began screening departing passengers for symptoms of Ebola. A study of the effectiveness of this has concluded that it has probably prevented 3 cases of Ebola per month from leaving the affected countries.

Returning health workers

There is concern that people returning from affected countries, such as health workers and reporters, may be incubating the disease and become infectious after arriving. A number of agencies have issued guidelines for returning workers; examples are CDC, MSF, Public Health England, and Public Health Ontario. Generally these recommend a risk assessment based on the likelihood of exposure. People in the low risk category are recommended to self-monitor for 21 days for symptoms which may indicate Ebola; there are more stringent requirements for those judged to be at higher risk.

The United Nations is concerned about travel restrictions placed on medical workers returning from West Africa and has issued a statement disapproving of the excessive quarantine of medical personnel. The US Centers for Disease Control and Prevention recommends monitoring of exposed people for 21 days but does not require quarantine, in which they are kept away from others, however some states in the United States have placed health care workers and others under mandatory 21-day quarantine. Speaking on lengthy quarantines for health care workers, US President Barack Obama said that "subjecting returning health-care workers to lengthy quarantines is motivated by fear, not science, and will be counterproductive because it will dissuade people from joining the fight against the disease in West Africa."

On 7 October, the governor of Connecticut signed an order authorizing the mandatory quarantine for 21 days of anyone, even if asymptomatic, who had direct contact with Ebola patients. On 24 October, the governor of New York, Andrew Cuomo, and the governor of New Jersey, Chris Christie, issued similar quarantine authorizations following an Ebola case reported in New York City. The quarantine affects people, in particular health care workers, entering the United States through JFK and Newark airports in New York and New Jersey respectively. Governor Christie said at a news conference with Governor Cuomo that "we are no longer relying on CDC standards." National Institute of Health expert Anthony Fauci has urged against these mandatory quarantines, warning that they would further discourage American healthcare workers from traveling to affected areas.

The first health care worker to be quarantined, Kaci Hickox, a nurse from Maine who was returning after working with Doctors Without Borders, was placed in mandatory quarantine in a tent outside of a Newark hospital in accordance with the new policy measures. Under threat of legal action, Hickox was allowed to return to her home in northern Maine on 27 October, where she remained under mandatory quarantine. After Hickox announced she would not comply with the isolation protocols in Maine, Maine Governor Paul LePage announced he was joining with his state's health department in seeking legal authority to enforce the quarantine. The next day a judge denied the request to enhance the quarantine order saying, "The court is fully aware of the misconceptions, misinformation, bad science and bad information being spread from shore to shore in our country with respect to Ebola. The court is fully aware that people are acting out of fear and that this fear is not entirely rational." Hickox has stated that she will continue to comply with voluntary direct active monitoring per CDC quidelines.

Treatment

No proven Ebola virus-specific treatment presently exists, however there are measures that can be taken that will improve a patient's chances of survival. Ebola symptoms may begin as early as two days or as long as 21 days after one is exposed to the virus. They usually begin with a sudden influenza-like stage characterized by feeling tired, fever, and pain in the muscles and joints. Later symptoms may include headache, nausea, and abdominal pain. This is often followed by severe vomiting and diarrhoea.

Without fluid replacement, such extreme loss of fluids leads to dehydration which may lead to hypovolaemic shock, a condition which occurs when there isn't enough blood for the heart to pump through the body. If a patient is alert and is not vomiting, oral rehydration fluids may be given, but patients who are vomiting or are delirious must be treated with intravenous fluids. In past outbreaks it has been noted that some patients may experience the loss of blood through bleeding internally and/or externally, however early data suggests that bleeding has been a rare symptom in this particular outbreak. On November 7, a group of scientists proposed that "by harnessing antibodies produced by survivors of the deadly outbreak", a cure could come about; this is based on the approach of "passive immunization."

Prognosis

Ebola virus disease has a high risk of death in those infected which varies between 25 percent and 90 percent of those who have contracted the disease. The case fatality rate (CFR), in previous Ebola infections is 50%, however it is known that the Zaire species, which is responsible for the current outbreak, carries a higher death rate. The CDC has reported a CFR for the current epidemic of about 71%. Care settings that have access to medical expertise may increase survival by providing maintenance of hydration, circulatory volume, and blood pressure.

The disease affects males and females equally and the majority of those that contract Ebola disease are between 15 and 45 years of age. For those over 45 years of age, a fatal outcome has been more likely in the current epidemic, as has also been noted in past outbreaks. Only rarely do pregnant women survive. A midwife who works with MSF in a Sierra Leone treatment center states that she knew of "no reported cases of pregnant mothers and unborn babies surviving Ebola in Sierra Leone."

It has been suggested that the loss of human life is not limited to Ebola victims alone. Many hospitals have shut down leaving people with other medical needs without care. A spokesperson for the UK-based health foundation the Wellcome Trust said in October that "the additional death toll from malaria and other diseases likely to exceed that of the outbreak itself". Doctor Paul Farmer states "Most of Ebola's victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts."

Level of care

Local authorities have not had resources to contain the disease, with health centres closing and hospitals overwhelmed. In late June, the Director-General of MSF 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.

In late August, 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 35% of its need for patient beds, and Liberia is meeting only 20% of its need.

Healthcare settings

A number of Ebola Treatment Centres have been set up in the area, supported by international aid organisations and staffed by a combination of local and international staff. Each treatment centre is divided into a number of distinct and rigorously separate areas. For patients, there is a triage area, and low- and high-risk care wards. For staff, there are areas for preparation and decontamination. An important part of each centre is an arrangement for safe burial or cremation of bodies, required to prevent further infection.

Although the WHO does not advise caring for Ebola patients at home, it is an option and even a necessity when no hospital treatment beds are available. For those being treated at home, the WHO advises informing the local public health authority and acquiring appropriate training and equipment. UNICEF, USAID and the NGO Samaritan's Purse have begun to take measures to provide support for families that are forced to care for patients at home by supplying caregiver kits intended for interim home-based interventions. The kits include protective clothing, hydration items, medicines, and disinfectant, among other items. Even where hospital beds are available, it has been debated whether conventional hospitals are the best place to care for Ebola patients, as the risk of spreading the infection is high. The WHO and non-profit partners have launched a program in Liberia to move infected people out of their homes into ad hoc centres that will provide rudimentary care.

Protective clothing

The Ebola epidemic has caused an increasing demand in protective clothing. A full set of protective clothing includes a suit, goggles, mask, socks and boots, and an apron. Boots and aprons can be disinfected and reused, but everything else must be destroyed. Health workers change garments frequently, discarding gear that has barely been used. This not only uses a great deal of time but also exposes them to the virus because for health care workers wearing protective clothing, one of the most dangerous times for catching Ebola is while suits are being removed.

The protective clothing set that MSF uses cost about $75 apiece. Staff who have returned from deployments to West Africa say the clothing is so heavy that it can be worn for only about 40 minutes at a stretch. A physician working in Sierra Leone has said, "After about 30 or 40 minutes, your goggles have fogged up; your socks are completely drenched in sweat. You're just walking in water in your boots. And at that point, you have to exit for your own safety...Here it takes 20-25 minutes to take off a protective suit and must be done with two trained supervisors who watch every step in a military manner to ensure no mistakes are made, because a slip up can easily occur and of course can be fatal." According to some reports, protective outfits are beginning to be in short supply and manufacturers have started to increase their production, but the need to find better types of suits has also been raised.

USAID published an open competitive bidding for proposals that address the challenge of developing "... new practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed (1) to help health care workers provide better care and (2) transform our ability to combat Ebola".

Deaths of healthcare workers

In August, it was reported that healthcare workers 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 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.

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, and workers could be in these 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 a 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".

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. 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". 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. In August, a well-known Nigerian physician, Ameyo Adadevoh, died. She was posthumously praised for preventing the Nigerian index case from leaving the hospital at the time of diagnosis, thereby playing a key role in curbing the spread of the virus in Nigeria.

By 11 November, the WHO reported 570 workers had been infected and 324 had died. Liberia has been especially hard hit with over half the total cases (332 with 162 deaths) reported. Sierra Leone registered 128 cases with 102 fatalities, thus indicating a death toll of 79.5% in Sierra Leone. Guinea reported 93 infected cases with 51 deaths. One infected case in Spain was reported, as well as three in the United States. In Nigeria 11 healthcare workers were also infected and 5 deaths were recorded. Mali reported 2 with 1 death to date.

Experimental treatments

There is as yet no known effective medication or vaccine. The director of the US National Institute of Allergy and Infectious Diseases has stated that the scientific community is still in the early stages of understanding how infection with the Ebola virus can be treated and prevented. 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.

A number of experimental treatments are being considered for use in the context of this outbreak, and are currently or will soon undergo clinical trials, but it will still be some time before sufficient quantities have been produced for widespread trials. On 13 November, MSF announced that trials of three possible treatments - serum, brincidofovir and favipiravir (see below) - would start during November in Ebola treatment centres.

• Serum Transfusion - Identified as a promising method since the early 1970s days of Ebola research, the WHO has recognised that transfusion of whole blood or purified serum from Ebola survivors is the therapy with the greatest potential to be implemented in the short term, although there is little information on its efficacy. On 21 October Dr Marie Paule Kieny, WHO assistant director general for health system and innovation, announced the development of partnerships in the three countries which would be able to safely extract plasma for treatment of infected patients. The first of these is likely to become operational in Liberia during November.

• ZMapp, a combination of monoclonal antibodies. The limited supply of the drug has been used to treat 7 individuals infected with the Ebola virus. Although some of them have recovered, the outcome is not considered to be statistically significant. ZMapp has proved highly effective in a trial involving rhesus macaque monkeys. Texas A&M University stated on 8 October that it was preparing to mass-produce the drug, in its Center for Innovation in Advanced Development and Manufacturing, pending final approval.
• TKM-Ebola, an RNA interference drug. A Phase 1 clinical trial involving healthy volunteers was started in early 2014 but suspended because of concern over side effects; however the FDA has approved emergency use to treat patients actually infected with the virus.
• Favipiravir (Avigan), a drug approved in Japan for use against influenza; the drug appears to be useful in a mouse model of Ebola disease, and a clinical trial is being planned for Ebola patients in Guinea, due November. The drug has been tried on four Ebola patients who subsequently recovered, but this outcome is not statistically significant.
• BCX4430 is a broad-spectrum antiviral drug developed by BioCryst Pharmaceuticals and currently being researched as a potential treatment for Ebola by USAMRIID. The drug has been approved to progress to Phase 1 trials, expected late in 2014.
• Brincidofovir, another antiviral drug, has been granted an emergency FDA approval as an investigational new drug for the treatment of Ebola after it was found to be effective against Ebola virus in in vitro tests. On 16 October, it was cleared to start clinical trials.
• JK-05 is an antiviral drug developed by the Chinese company Sihuan Pharmaceutical along with the Chinese Academy of Military Medical Sciences. In tests on mice, JK-05 shows efficacy against a range of viruses, including Ebola. It is claimed to have a simple molecular structure, which should be readily amenable to synthesis scale-up for mass production. The drug has been given preliminary approval by the Chinese authorities to be available for Chinese health workers involved in combating the outbreak, and Sihuan are preparing to conduct clinical trials in West Africa.

Experimental preventative vaccines

• In September, an experimental vaccine, now known as the cAd3-ZEBOV vaccine, commenced simultaneous Phase 1 trials, being administered to volunteers in Oxford and Bethesda. The vaccine was developed jointly by GlaxoSmithKline and the NIH. During October the vaccine is being administered to a further group of volunteers in Mali. If these trials are 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.
• A second vaccine candidate, rVSV-ZEBOV, has been developed by the Public Health Agency of Canada. On 29 October, the Wellcome Trust announced that multiple trials are to begin swiftly in healthy volunteers in Europe, Gabon, Kenya, and the USA. This is the latest of several international commitments to fast-track early tests of candidate Ebola vaccines so they could be available for trial in West Africa by the end of the year, and if successful deployed more widely in 2015.
• A third vaccine candidate, consisting of a prime-boost regimen of an adenovirus vaccine component from Crucell (Johnson & Johnson) and a modified vaccinia Ankara component from Bavarian Nordic is being prepared for clinical trials in early 2015. Johnson & Johnson have announced their commitment to accelerate the development of the vaccine and will produce more than 1 million doses of the vaccine during 2015.

Outlook

Since the beginning of the outbreak, there has been considerable difficulty in getting reliable estimates both of the number of people affected, and of the geographical extent of the outbreak. The three countries which are most affected, Sierra Leone, Guinea and Liberia, are among the poorest in the world, with extremely low levels of literacy, few hospitals or doctors, poor physical infrastructure, and poorly functioning government institutions.

One effect of the epidemic has been to weaken the institutions which already exist as healthcare and government workers become overwhelmed by the workload, in some cases abandoning their posts, or succumb to infection. Since the symptoms of EVD resemble other diseases such as malaria which are common in the area, even diagnosis is uncertain unless a blood sample can reach one of the few testing centres which are equipped to perform PCR or ELISA tests. WHO, MSF and the CDC have warned that the official counts of EVD cases and deaths are not consistent with field observations, and are likely to understate the extent of the epidemic.

Statistical measures

Calculating an accurate case fatality rate (CFR) is difficult for an ongoing epidemic due to differences in testing policies, the inclusion of probable and suspected cases, and the inclusion of new cases that have not run their course. In late August, the WHO made an initial CFR estimate of 53% though this included suspected cases. On 23 September, the WHO released a revised and more accurate CFR of 70.8% (with 95% confidence intervals of 68.6%-72.8%), derived using data from patients with definitive clinical outcomes.

The basic reproduction number (BRN, or R₀) 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; if the rate is greater than 1, the infection will continue to spread in a population. The BRN of the current outbreak is estimated to be between 1.71 and 2.02.

Projections of future cases

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 three 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 31 August, 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 BRN 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. The researchers believe this is unlikely but say that Ebola "must be regarded as a Public Health Emergency of International Concern".

On 9 September, Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Germany, controversially announced that the containment fight in Sierra Leone and Liberia has already been "lost" and that the disease would "burn itself out". Writing in The New York Times 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 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. In a 23 September WHO report, the WHO revised their previous projection, stating that they expect the number of Ebola cases in West Africa to be in excess of 20,000 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.

On 2 September, an assessment of the probability of Ebola virus disease case importation in countries across the world was published in PLOS Currents Outbreaks. The projections are based on simulations of epidemic spread worldwide. The analysis was updated with simulations based on new data on 6 October, and the updated results are available online. On 14 October, during a news conference in Geneva, the assistant director-general of the WHO stated that there could be as many as 10,000 new Ebola cases per week by December 2014.

A third of all Ebola cases ever documented were diagnosed by September 2014. The WHO Ebola Response team reported that the doubling times of the outbreak were 15.7 days in Guinea, 23.6 days in Liberia and 30.2 days in Sierra Leone.

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, a cordon sanitaire, or fear of human contact, which leads to loss of income for producers and traders.
• Movement of people away from affected areas has disturbed agricultural activities. The UN 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.
• Many airlines have suspended flights to the area.
• Foreign mining companies have withdrawn non-essential personnel, deferred new investment, and cut back operations.
• 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 are ballooning and their economies contract sharply.
• On 8 October, the World Bank issued a report which estimated overall economic impacts of between $3.8 billion and $32.6 billion, depending on the extent of the outbreak and the speed with which it can be contained. The economic impact would be felt most severely in the three affected countries, with a wider impact felt across the broader West African region.

Responses

In July, the World Health Organization, a United Nations agency which coordinates international response to disease outbreaks, convened an emergency meeting with health ministers from eleven countries and announced collaboration on a strategy to co-ordinate technical support to combat the epidemic. In August they published a roadmap to guide and coordinate the international response to the outbreak, aiming to stop ongoing Ebola transmission worldwide within 6–9 months, and formally designated the outbreak as a Public Health Emergency of International Concern. This is a legal designation used only twice before (for the 2009 H1N1 (swine flu) pandemic and the 2014 resurgence of polio) which invokes legal measures on disease prevention, surveillance, control, and response, by 194 signatory countries.

There has been heavy criticism of the WHO from some aid agencies because its response has been perceived as slow and insufficient, especially during the early stage of the outbreak. In October, the Associated Press reported that in a leaked preliminary draft report the WHO admitted to mistakes saying that they had missed chances to stop the spread of Ebola "thanks to incompetent staff, a lack of information, and bureaucracy due to 'politically motivated appointments'." Peter Piot, co-discoverer of the Ebola virus, has called the WHO staff "really not competent.”

In September, the United Nations Security Council declared the Ebola virus outbreak in West Africa "a threat to international peace and security" and unanimously adopted a resolution urging UN member states to provide more resources to fight the outbreak; the WHO stated that the cost for combating the epidemic will be a minimum of $1 billion.

During October, WHO and UNMEER announced a comprehensive 90-day plan to control and reverse the epidemic of EVD. The immediate objective is to isolate at least 70% of EVD cases and safely bury at least 70% of patients who die from EVD by 1 December 2014 (the 60-day target) - this has become known as the 70:70:60 program. The ultimate goal is to have capacity in place for the isolation of 100% of EVD cases and the safe burial of 100% of casualties by 1 January 2015 (the 90-day target). Many nations and charitable organizations are cooperating to realise this plan.

Timeline of reported cases and deaths

Data sources

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 reports are sourced from official information from the affected countries' health ministries. The WHO has stated the reported numbers "vastly underestimate the magnitude of the outbreak", estimating there may be 3 times as many cases as officially reported. As an example, Sierra Leone has grown cases at a much faster rate, while simultaneously at an insoluble lower reported death rate versus those in Guinea and Liberia. And Liberia was singled out in the 8 and 14 October reports from WHO, noting "There continue to be profound problems affecting data acquisition in Liberia... it is likely that the figures will be revised upwards in due course."

Characterizations of rate of growth

On October 23 WHO noted at a press conference that exponential increase of cases continued in the countries with the most intense transmission (Guinea, Liberia and Sierra Leone). A study estimated during the first 9 months of the outbreak the disease was transmitted onwards to approximately 1.7-2 people for each case.

Understanding the data and its limitations

Each row of the table represents the best available information cross-checked from multiple sources on the day it was reported. The data may be inaccurate for the following reasons:

• Each data source or report may or may not include suspected cases that have not yet been confirmed.
• Each source or report may or may not include probable cases.
• Case numbers may be revised downward if a probable or suspected 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.)
• The reports usually refer to cumulative data totals since the start of the 2014 epidemic. When new data becomes available or old data is revised the correction could apply either to the past or the present.
• The number of deaths may revise downwards if it is later found from testing those deaths were not from Ebola.
• There are variable delays in gathering, correcting and reporting the data from multiple sources.

It is not possible to infer the rate of growth or decline in the spread of the disease from the cumulative data or the graphs; they simply reflect a timeline of the available data as reported on any given date. The real-world spread could be slowing while reported cumulative cases rise at a faster rate due to improved reporting, or the real-world spread could be increasing with flat cumulative data due to lack of reporting.

• Cumulative totals of cases and deaths over time
• Cumulative totals in log scale
• The reported weekly cases of Ebola in West Africa as listed on Misplaced Pages Ebola virus epidemic in West Africa; some values are interpolated
• Cumulative number of cases by country, using a linear scale
• Cumulative number of cases by country, using a logarithmic scale
• Cases based on population, using a linear scale
• Cases based on population, 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 ≥ may not be consistent due to under reporting.

1. Guinea and Sierra Leone up to the end of 11 November, and the Ministry of Health of Liberia up to the end of 10 November. Sierra Leone deaths as per Government report
2. All totals as per WHO report for 9 Nov except Sierra Leone deaths as per Government report
3. All totals as per WHO report for 4 Nov except Guinea, dated 3 Nov 2014 and Sierra Leone as per Government report
4. 2 November Liberian and Sierra Leone as per Gov. Guinea as per OCHA.
5. 30 October Liberian and Sierra Leone as per Gov. Guinea as per OCHA.
6. Liberia and Sierra Leone countries date as per governments. Guinea as per OCHA. All cases dates 24 October. Death toll for Liberia as per latest WHO report.
7. 19 October as per WHO for all except Liberia 18 October.
8. 17 October data are based on official information reported by Ministries of Health up to the end of 17 October for all governments. Liberian and Sierra Leone as per Gov. Guinea as per OCHA. Rest stat as per WHO 17 Oct report
9. 12 October as per WHO Spain and US as per news reports
10. WHO report is for 7 Oct and not 8 Oct, updated with 7 Oct dates for Sierra Leone
11. 5 October 275 of the additional deaths reported this week from Sierra Leone are the result of a retrospective analysis of hospital records. Data are based on official information reported by Ministries of Health up to the end of 5 October for Guinea and Sierra Leone, and 4 October for Liberia. Liberian numbers are likely an underestimate and may be adjusted upwards at a later date.
12. 1 October as per reports WHO. Liberia subject to change.
13. 28 September Liberia and Guinea reports as per respective WHO and Sierra Leone as per government(2304 cases and 622 deaths according to WHO report). Nigeria and Senegal stat. Note US case only dated 29 September but been in US since 28 September
14. 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).
15. 21 September Liberia, Guinea as per WHO report. modified with Sierra Leone death toll as per Gov which is lower than WHO death toll (597)
16. 14 September Guinea as per WHO report. Updated with Liberia numbers as per Gov. Updated with Sierra Leone death toll as per Gov
17. 7 Sept WHO report Sierra Leone death rate suspected added up double in report.

References

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External links

• "Outbreak Updates". World Health Organization (WHO).
• "Outbreak Updates". US Centers for Disease Control and Prevention (CDC).
• Ebola Outbreak in West Africa Updates Food and Agriculture Organization of the UN (FAO)
• 2014 Ebola Outbreak Timeline Healthmap.org
• How Ebola has grown since March (Graphic)
• Ebola Communication Network Platform to share communication materials regarding the Ebola epidemic
• Fighting Ebola: A Grand Challenge for Development Platform to collect and distribute ideas to stop the Ebola epidemic
• "Ebola outbreak in West Africa". European Centre for Disease Prevention and Control (ECDC).

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