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Western African Ebola epidemic

Situation map of the outbreak
Date	December 2013 – present
Location	Guinea, Liberia, Nigeria, Senegal, Sierra Leone
Casualties
Cases / Deaths (as of 17 September 2014)  Total: 5,762 / 2,746  Guinea: 965 / 623  Liberia: 3,022 / 1,578  Nigeria: 21 / 8  Senegal: 1 / 0  Sierra Leone: 1,753 / 537 See notes for 17 Sept on Timeline Section

As of 2014, an epidemic of the Ebola virus disease (EVD) is ongoing in West Africa. The outbreak 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 exceeded the total of all cases from previous known outbreaks. A separate outbreak in the Democratic Republic of the Congo that has 66 possible and confirmed cases and 37 deaths as of 12 September 2014 is believed to be unrelated.

As of 17 September 2014, the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and local governments reported a total of 5,762 suspected cases and 2,746 deaths (3,245 cases and 1,601 deaths having been laboratory confirmed). Many experts believe that the official numbers substantially understate the size of the outbreak because of families' widespread reluctance to report cases. On 28 August, the WHO reported an overall case fatality rate (CFR) estimate of 52%, considerably lower than an average of the rates reported from previous outbreaks. However, difficulties in collecting information and the methodology used in compiling it may be resulting in an artificially low number. A more accurate method that observed patient outcomes in Sierra Leone found a CFR of 77%.

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

Researchers believe a 2-year-old boy was the first human case of this Ebola virus disease epidemic. He died 6 December 2013 in the village of Meliandou, Guéckédou Prefecture, Guinea. His mother, sister and grandmother then became ill with symptoms consistent with Ebola infection and also died. People infected by those victims spread the disease to other villages.

On 19 March, the Guinean Ministry of Health acknowledged a local outbreak of an undetermined viral hemorrhagic fever; the outbreak, ongoing since February, had sickened at least 35 people and killed 23. Ebola was suspected, and 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. The first cases broke out in the Kailahun District, near the border with Guéckédou in Guinea, and were reported on 25 May. 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 EVD 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 16 September, the outbreak appears to have stabilised with 22 confirmed cases and eight deaths, no new cases having been confirmed for two weeks.

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 has subsequently recovered, but 67 possible contacts are being monitored in order to prevent further spread of the disease.

Nations with local transmission

Guinea

Researchers believe that the first human case of the Ebola virus disease leading to the 2014 outbreak was a 2-year-old boy who died 6 December 2013 in the village of Meliandou, Guéckédou Prefecture. In early August, Guinea closed its borders with both Sierra Leone and Liberia to help contain the spread of the disease, as more new cases were being reported in those countries than in Guinea.

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 eight workers who had been distributing Ebola information and doing disinfection work were found in a village latrine in a village near Guéckédou. The workers had been attacked and died several days earlier. 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 villagers 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 a nearby village when rumors were spread that people were being contaminated when health workers were spraying a market area to decontaminate it.

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.

Sierra Leone

The first person reported infected was a tribal healer. She 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 1 April, Sierra Leone declared a state of emergency and instituted measures to screen travelers from Guinea and Liberia. On July 30, it declared a state of emergency and deployed troops to quarantine hot spots.

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. That disease 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 loudspeakers. Also in August, Sierra Leone passed a law that subjected anyone hiding someone believed to be infected to two years in jail. When enacted, a top parliamentarian was critical of failures by neighboring countries to stop the outbreak.

On 26 August, the WHO shut down one of two laboratories after a health worker was infected. It was situated in the Kailahun district, one of the worst affected areas. This may disrupt efforts to increase the global response to the outbreak of the disease in the district. "It's a temporary measure to take care of the welfare of our remaining workers," WHO spokesperson Christy Feig announced. He did not specify how long the closure would last, but they will return after the WHO assessment of the situation. The medical worker was one of the first WHO staff infected by the Ebola Virus. The worker was treated at a hospital in Kenema and then evacuated to Germany.

In September, officials in Sierra Leone ordered a three-day lockdown, telling people to stay inside their homes between September 19 and 21, during which time they hope to identify all those affected with Ebola and remove them from their homes. The plan has been criticized by Doctors Without Borders who question whether the measure will help and may actually hinder identification problems: “Without a place to take suspected cases – to screen and treat them – the approach cannot work. It has been our experience that lockdowns and quarantines do not help control Ebola they end up driving people underground and jeopardizing the trust between people and health providers. This leads to the concealment of potential cases and ends up spreading the disease further.”

Nigeria

Nigeria Ebola areas-2014

Nigeria Situation Map as of 5 September 2014
Date	July 2014 – present
Casualties
Cases / Deaths (as of 13 September 2014)  Nigeria: 21 / 8

The first case in Nigeria was introduced. Liberian-American Patrick Sawyer flew from Liberia and became violently ill upon arriving at Nigeria's capital Lagos. Sawyer died five days later, on 25 July. 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; health officials were placed at entry points to conduct tests on people arriving in the country. On 19 August, it was reported that the doctor who treated Sawyer, Ameyo Adadevoh, had also died of Ebola disease. Adadevoh, a descendant of Herbert Macaulay and Samuel Ajayi Crowther 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 6 August, authorities confirmed the death of a nurse who had treated Sawyer.

In July, Arik Air, Nigeria's main airline, stopped flights to Liberia and Sierra Leone.

On 9 August, the Nigerian National Health Research Ethics Committee, the organization regulating research ethics in the country, issued a statement waiving the regular administrative requirements that limit the international shipment of any biological samples out of Nigeria. The statement also supports the use of non-validated treatments without prior review and approval by a health research ethics committee.

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. 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: "Efforts are currently ongoing to scale up and strengthen all aspects of response, including contact tracking, public information and community mobilization, case management and infection prevention and control, and coordination. There is now increased disease surveillance system in a bid to monitor, control, and prevent any occurrence of the disease".

On 22 August, a doctor who treated a Liberian diplomat (Olubukun Koye) in the Mandate Hotel —who had had contact with Patrick Sawyer—died in Port Harcourt from Ebola. The BBC report said the diplomat had escaped from quarantine in Lagos and traveled to the city for medical treatment where he survived after being treated. As of the end of August, the total number of deaths from Ebola in Nigeria stood at six. The Good Heart Hospital, where the doctor had been admitted before his death, and the hotel where he had treated the diplomat were shut down. As a result, suspected contacts were subsequently quarantined. On 11 September, Nigeria announced that it no longer had even a single case of Ebola but would need to wait for about a week more before declaring itself completely Ebola-free.

Nations with imported cases

Senegal

In March, the Senegal Ministry of Interior ordered all movements of people through the southern border with Guinea to be suspended indefinitely to prevent the spread of the disease, according to a statement published on 29 March by state agency APS.

On 29 August, the Senegalese Health minister, Awa Marie Coll Seck, announced the first case of Ebola in the country. The patient arrived from the neighbouring country Guinea, where the virus was first reported. The case has been confirmed in Senegal. The patient, a university student from Guinea, is being treated in Dakar. Samples were sent to the Institut Pasteur, where Ebola was confirmed. The WHO was informed of the situation on 30 August and is treating the situation "as a top priority emergency", and it has now dispatched operational personnel to Dakar.

France

On 17 September it was announced that a French volunteer health worker in Liberia had become infected. She will be transferred to a hospital in France for treatment.

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.

India

On 27 August, a Health Ministry official said that 112 Indian citizens and four Nepalese citizens had landed in Mumbai and Delhi from Liberia. Of the 17 who had arrived in Delhi, one had fever symptoms and had been quarantined at the Airport Health Organisation (APHO), an airport medical facility. Six others were screened for Ebola, and five passengers who arrived on routine flights from affected countries showing fever symptoms had also been quarantined. Earlier, it was reported that an isolation facility with 120 beds was being created in the Hindu Hriday Samrat Jogeshwari trauma care hospital by Brihanmumbai Municipal Corporation (BMC). On 28 August, the Health Ministry reported that 821 people were being monitored and tracked for the Ebola virus.

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.

United Kingdom

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

United States

American aid worker Kent Brantly, a physician, became infected with Ebola while working in a Monrovia treatment center as medical director for the aid group Samaritan’s Purse; Nancy Writebol, one of Brantly's missionary co-workers, became infected at the same time. Both were flown to the United States at the beginning of August for further treatment in Atlanta's Emory University Hospital, near the headquarters of the Centers for Disease Control. On 21 August, both Brantly and Writebol were discharged from Emory University Hospital, having recovered from the virus.

On 4 September, a Boston physician, Rick Sacra, was airlifted from Liberia to be treated in the United States. He is the third US missionary, working for Serving In Mission (SIM), who has tested positive for the disease. Sacra is being treated in Omaha at the Nebraska Medical Center. The doctor did not get infected while treating Ebola patients, but was exposed to the virus while delivering babies at a hospital in Liberia. On 9 September, it was reported that Sacra is receiving an experimental therapy (not ZMapp) and it was later announced that he had received a blood transfusion from Kent Brantly, an American physician who has recovered from the disease. It has been theorized that transfusing blood products from former Ebola patients may assist a diseased person's immune system to fight the disease. As of 11 September, he has shown "remarkable" improvement though recovery remains uncertain.

On 9 September, the fourth U.S. citizen who contracted the Ebola virus arrived at Emory University Hospital in Atlanta for treatment. The patient was airlifted from Sierra Leone and landed at Dobbins Air Reserve Base. The identity of the patient, a male doctor working for the WHO in Sierra Leone, has not been released. According to doctors at the hospital, he will not be receiving any experimental treatment and will only receive supportive care to boost his immune system. The patient exited the ambulance and was assisted into the hospital while walking on his own.

Virology

Ebola virus disease is caused by four of five viruses classified in the genus Ebolavirus, family Filoviridae, order Mononegavirales. The four disease-causing viruses are Bundibugyo virus, Sudan virus, Taï Forest virus, and one called simply, Ebola virus (formerly and often still called the Zaire Ebola virus). Ebola virus is the most dangerous of the known Ebola disease-causing viruses, as well as being responsible for the largest number of outbreaks. The strain of virus affecting people in the current outbreak is believed to be a member of the Zaire lineage. An article published in the New England Journal of Medicine on-line in April 2014 asserted that while the Ebola virus in Guinea shared 97% of its genetic code with the Zaïre lineage, it was of a different clade from the strains present in outbreaks in the Democratic Republic of Congo and Gabon, and that it constituted a new strain indigenous to Guinea, and was not imported from Central Africa to West Africa. This result, however, was contradicted by two subsequent reports.

The first of these reports reached the conclusion that the outbreak "is likely caused by a Zaire ebolavirus (Ebola virus) lineage that has spread from Central Africa into Guinea and West Africa in recent decades, and does not represent the emergence of a divergent and endemic virus." A second report published in June 2014 supports the latter view, determining that it was "extremely unlikely that this virus falls outside the genetic diversity of the Zaïre lineage" and that their analysis "unambiguously supports Guinea 2014 EBOV as a member of the Zaïre lineage."

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

Containment efforts

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. 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.

Médecins Sans Frontières described the situation as being "totally out of control" in late June. Urging the world to offer aid to the affected regions, the Director-General 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."

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.

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.

Travel restrictions

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."

Complications

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.

Adequate equipment has not been provided for medical personnel, with even a lack of soap and water for hand-washing and disinfection. Containment efforts are further 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. Semen may be infectious in survivors for up to three months. 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."

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 was forced to suspend operations in southeast Guinea after they were threatened by a group of men armed with knives. In the village of Wome in Guinea, at least eight aid-workers were murdered by suspicious villagers with machetes and their bodies dumped in a latrine on September 18.

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."

Healthcare providers

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. In August, it was reported that healthcare workers have represented nearly 10 percent of the cases and fatalities, significantly impairing the ability to respond to the outbreak in a country which already faces a severe shortage of doctors. In August, the WHO reported that more than 240 health care workers had developed Ebola and more than 120 had died; by 14 September, the cases had risen to 318 with 151 deaths. 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.".

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.

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."

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.

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, an expert panel of the WHO on 12 August endorsed the use of interventions with as-yet-unknown effects both for treatment and for 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.

Projections

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 have estimated the reproduction number of the EVD epidemic in West Africa between 1.2 and 2.5, with variations between countries and time during the outbreak. The basic reproduction number of EVD together with its generation time, which is the time between initial infection and transmission to others, cause the cumulative number of infected cases to double every two to three weeks in some affected areas.

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 does not provide details of how it made this total casualty estimate or a more detailed projection of how Ebola casualty statistics might evolve over time. It includes an assumption that some country or countries will pay the required cost of their plan, estimated at half a billion dollars.

A number of epidemiologists have highlighted that the WHO projection of a total of 20,000 cases might be 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: "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 3 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".

Democratic Republic of Congo

Democratic Republic of Congo-2014

DRC Ebola area as of 6 September 2014
Casualties
Cases / Deaths (as of 15 September 2014)  DR Congo: 71 / 40

An outbreak of Ebola Virus in Democratic Republic of 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, and it is believed that the outbreak in DRC is unrelated to the ongoing outbreak in West Africa.

On 20 August, several people, including four 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. By 21 August, 13 people were reported to have died with similar symptoms.

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. 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 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 18 September, the WHO raised the number of cases to 71 and the death toll to 40 from possible or confirmed Ebola cases.

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 $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 said it is seeking $490 million in funding to fight the outbreak. 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 WHO Assistant Director General, Bruce Aylward, announced that the cost for combating this disease epidemic will spiral to a staggering $1 billion. "We don't know where the numbers are going on this," according to Aylward. In addition aid workers have predicted an "explosive" increase in new case numbers in the following days in the epidemic area.

US Centers for Disease Control

On 31 July, US health officials from the US Centers for Disease Control (CDC) issued a travel advisory for Guinea, Liberia, and Sierra Leone, warning against non-essential travel. By 26 August, the CDC had issued a Level 3 travel warning for Sierra Leone, Guinea, and Liberia and a Level 2 travel warning for Nigeria. The Level 3 warning is the highest that can be issued and will be in place until 27 February 2015. It means that United States residents must avoid nonessential travel to the three countries worst hit by the virus.

By the beginning of August, the US 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 6 August, the Centers for Disease Control moved its Ebola response to Level 1 (the highest on a scale from 1 to 6) to increase the agency's ability to respond to the outbreak.

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 agencis.

Economic Community of West African States

On 30 March, during the 44th Summit of the heads of state and government of West Africa, Economic Community of West African States (ECOWAS) disbursed US$250,000 to deal with the outbreak. At the event in July 2014, the Nigerian government donated US$500,000 to the Liberian government to aid the fight against the virus.

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.

World Food Programme

On 18 August, the World Food Programme of the United Nations announced plans to mobilise food assistance for an estimated 1 million people living in restricted access areas.

United Nations Security Council

On September 18, 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.” Accra in Ghana will serve as a base for UNMEER from where they will work in close relation with the governments of the affected areas.

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)
• Withholding visitor visas from nationals of the affected countries, closing borders and cancelling flights. (Equatorial Guinea, Kenya, Colombo)
• Precautions such as isolation facilities, training of staff, and biocontainment exercises. (Malta)

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.

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.

Chad

The Prime Minister of Chad, Kalzeubet Pahimi Deubet, said it will follow in the footsteps of South Africa and impose travel restrictions to and from the countries currently affected by the Ebola outbreak. Chad will close all its borders to Nigeria to prevent the spread of the disease to the country. He added that this would have an economic impact to Chad and the region, but the restrictions are necessary.

China

A Chinese plane carrying supplies worth 30 million yuan (4.9 million US dollars) arrived in Guinea, Sierra Leone, and Liberia on 11 August. This is their second Ebola relief after the first batch delivered in May to Guinea, Liberia, Sierra Leone, and Guinea-Bissau. The supplies include medical protective clothes, disinfectants, thermo-detectors, and medicines. China also sent three expert teams composed of epidemiologists and specialists in disinfection and protection as well as medical supplies to Guinea, Liberia, and Sierra Leone despite high risk of infection. Before their arrival, eight members of a Chinese medical team sent to assist patients in Sierra Leone's hospitals were quarantined after treating Ebola patients.

Some Chinese companies in West Africa 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 on Saturday discussed several hot issues, including Ebola, in their fourth meeting this year. The meeting in Nanjing, capital of east China's Jiangsu Province, was held before they attended the opening ceremony of the 2nd Summer Youth Olympic Games. 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 has provided emergency medical assistance to Ebola-hit countries and sent expert groups. 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.

Colombia

On 8 August, the Vice Minister of Health and Social Protection of Colombia, Fernando Ruiz, assured the public that the Government is preparing itself to face the virus even though Colombia's given conditions don't give Ebola the chance to natively spread since "the bat species in charge of transmitting the disease nor the practice of eating it aren't present in Colombia." Ruiz also stated that Colombians travelling to the affected parts of West Africa are being warned to take appropriate precautions. Previously, on 5 August, the Ministry of Health and Social Protection issued a press release stating that "since the month of April the National Government has been closely following and monitoring the outbreak of the Ebola virus in West Africa and the State has decided to adopt word by word the contingency plan prepared by the WHO."

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.

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.

India

On 8 August, India placed all of its airports on high alert and stepped up surveillance of all travellers entering the country from Ebola-affected regions. The Union Health Minister, Harsh Vardhan, issued a statement, "There is no cause for panic. We have put in operation the most advanced surveillance and tracking systems." From 9 August, passengers coming from Ebola-affected countries will have to complete a form before landing; the form has a check-list for symptoms and asks travellers from West Africa for information about places visited, length of stay and other important information.

"The form is ready and will be officially released by Saturday. We will request all airlines to direct their staff to distribute the form in-flight, like immigration forms are given before arrival," said Jagdish Prasad, director general of health services, Union Ministry of Health. In New Delhi, Ram Manohar Lohia Hospital in New Delhi has been designated as a treatment centre for Ebola Virus Disease (EVD) cases. A 24-hour emergency helpline will also be functional from Saturday. Its numbers are (011)-23061469, 3205 and 1302. The estimated 47,000 Indians in the affected countries are being contacted by area diplomatic missions and supplied with educational material about the disease.

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.

Morocco

Beginning in April, Morocco reinforced medical surveillance at the Casablanca airport, a regional hub for flights from and to West Africa. In early August, Liberian interior minister Morris Dukuly announced the Ebola death of a Liberian man in the country, but the Moroccan Ministry of Health announced that the person died of a heart attack, rather than Ebola.

Philippines

The Philippine Department of Foreign Affairs has raised Alert Level 2 in Guinea, Liberia, and Sierra Leone and has temporarily halted the sending of Filipino workers to the affected countries since 30 June. Filipino seafarers are also cautioned about potentially contracting Ebola when their ships dock in affected countries. 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.

Qatar

Qatar has banned the import of live animals, food and meat products from Guinea, Liberia, Sierra Leone, and Nigeria as a precaution against Ebola.

Seychelles

Seychelles introduced a visa requirement for the citizens of Sierra Leone, Liberia, Guinea-Bissau, Guinea Conakry, Nigeria, Cameroon, Chad, Niger, Burkina Faso, Mali, Benin, Ivory Coast, Ghana, Togo, Congo, D.R. Congo, Gambia, Mauritania, and Senegal. Citizens of these countries will require a visa until the Ebola outbreak is declared over. Members of the Sierra Leone national football team were refused visas over 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. In addition, the Saudi Ministry of Health advised citizens and residents of Saudi Arabia to avoid travelling to Liberia, Sierra Leone, and Guinea until further notice.

South Africa

On 21 August, South Africa announced a ban on all travelers from the three Ebola-hit West African nations. A government spokesman confirmed they are following other countries responses to the disease outbreak. The health ministry of South Africa confirmed that the country's citizens would be asked to limit travel to absolutely essential needs, if going to the countries involved in the current outbreak. All South Africans returning from these countries would only be allowed back after undergoing extensive medical tests, and quarantine, if necessary.

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 26 August, British Airways extended its ban on flights to Liberia and Sierra Leone until 31 December due to the declining public health situation.

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. An initial survey team consisting of military engineers will be sent to the country within the next couple of days. 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

On 31 July, health officials from the United States Centers for Disease Control and Prevention (CDC) issued a travel advisory for Guinea, Liberia, and Sierra Leone, warning against non-essential travel. By 26 August, the CDC had issued a Level 3 travel warning for Sierra Leone, Guinea, and Liberia and a Level 2 travel warning for Nigeria. The Level 3 warning is the highest that can be issued and will be in place until 27 February 2015. It means that United States residents must avoid nonessential travel to the three countries worst hit by the virus.

By the beginning of August, the CDC 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 6 August, the Centers for Disease Control moved its Ebola response to Level 1 (the highest on a scale from 1 to 6) to increase the agency's ability to respond to the outbreak.

On 29 August, the CDC issued a Level 2 travel warning for the Democratic Republic of the Congo (DRC), warning against contact with body fluids of people with Ebola.

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 and will provide additional safety to health workers in the area. The military will also assist in providing transportation of medical equipment. President Obama added that the steps are necessary to curtail the spread of the virus. 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 milllion over the next six months. U.S. Major General Darryl A. Williams, Commander, United States Army Africa, will be in place in Monrovia, Liberia, within the week to lead the effort. The general 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. The President said that the armed forces “are going to bring their expertise in command and control, in logistics, in engineering” to help do tasks ranging from bringing in aid workers and medical equipment to distributing supplies and information kits to families in high-risk areas so they can take the appropriate precautions. He added, “Our armed services is better at that than any organization on Earth.”

Ebola will be on the top of Obama's agenda list in the upcoming September meeting of the United Nations. Having already pledged 3,000 U.S. military personnel as an immediate relief and additional financial and medical assistance, the US will seek cooperation from other countries to join efforts against fighting the outbreak.

On 19 September Gen. Ray Odierno, the Military chief of staff, announced that the promised 3,000 troops will be deployed in the area within 30 days. This time will allow the troops being deployed to be properly prepared to deal with the outbreak. A small initial assessment team consisting of 12 members have already arrived in Monrovia together with some equipment on Wednesday 17 September. Two more aircraft with an estimated 45 member team is expected to arrive on the weekend of 20 September. 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.

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. The funds were released with immediate effect. 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. This brings the Seattle-based Foundation's total contribution to date over $60 million. “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, following the footsteps of the Bill & Melinda Gates 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 stated that "The disease is uncontained and out of control in West Africa."

Individual contributors

On 14 August, the Nigerian government said Aliko Dangote had donated 150 million naira 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

A timeline of the outbreak follows. Data came 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". Cases in remote areas may also be missed.

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.

Note: 31 August WHO SL death toll wrong

Note: 7 Sep WHO report Sierra Leone death rate suspected added up double in report.

Note: 10 Sep From Primary Source OCHA and Liberia government---Note Nigeria and Senegal stat

Note: 14 Sept Guinea as per WHO report. Updated with Liberia numbers as per Gov. Updated with Sierra Leone death toll as per Gov

Note: 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 stat.

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External links

• Outbreak Updates, World Health Organization (WHO).
• Outbreak Updates, US Centers for Disease Control and Prevention (CDC).

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