Farrar, Jeremy J

Piot, Peter

Jeremy J. Farrar

Peter Piot

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New England Journal of Medicine

The Ebola Emergency — Immediate Action, Ongoing Strategy

LSHTM Research Online

Farrar, JJ; Piot, P (2014) The Ebola Emergency - Immediate Action,Ongoing Strategy. The New England journal of medicine, 371 (16).pp. 1545-6. ISSN 0028-4793 DOI: 10.1056/NEJMe1411471Downloaded from: http://researchonline.lshtm.ac.uk/1947014/DOI: 10.1056/NEJMe1411471Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Copyright the publishersn engl j med 371;16 nejm.org october 16, 2014 1545e d i t o r i a lT h e  n e w  e ngl a nd  j o u r na l  o f  m e dic i n eThe Ebola Emergency — Immediate Action, Ongoing StrategyJeremy J. Farrar, M.D., Ph.D., and Peter Piot, M.D., Ph.D.The 25th known outbreak of Ebola virus infec-tion is unlike any of the previous epidemics. It has already killed over 2800 people — more than all previous epidemics combined; it’s affecting virtually the entire territory of three countries, involving rural areas, major urban centers, and capital cities; it has been going on for almost a year; and it is occurring in West Africa, where no Ebola outbreak had previously occurred. Above all, the epidemic seems out of control and has evolved into a major humanitarian crisis that has finally mobilized the world, with responses ranging from an emergency health mission launched by the United Nations Security Council to proposed military-style interventions and the global provision of emergency aid.The disintegration of the health care systems in the affected countries is already having a pro-found impact on the populations’ health beyond Ebola, as clinics close or become overwhelmed or nonfunctional. These health system effects will only worsen as the epidemic progresses: West Africa will see much more suffering and many more deaths during childbirth and from malaria, tuberculosis, HIV–AIDS, enteric and respiratory illnesses, diabetes, cancer, cardiovascular dis-ease, and mental health during and after the Ebola epidemic. Indeed, there is a very real dan-ger of a complete breakdown in civic society, as desperate communities understandably lose faith in the established systems.A report from the Ebola Response Team of the World Health Organization now published in the Journal presents the first comprehensive analysis of epidemiologic surveillance data on the West African epidemic.1 Though the com-pleteness and quality of the data are uncertain — collecting information under such extreme conditions is an enormous challenge, and the remarkable contribution of the data-collection teams in West Africa must be acknowledged — they provide a convincing case that the epidemic is still expanding, with a conservative projection that there will be close to 20,000 cases by early November. Without a more effective, all-out effort, Ebola could become endemic in West Africa, which could, in turn, become a reservoir for the virus’s spread to other parts of Africa and beyond.Yet despite the vast scale of the current out-break, the clinical manifestations of Ebola virus disease, the duration of illness, the case fatality rate, and the degree of transmissibility are simi-lar to those in earlier epidemics. It is therefore unlikely that the particularly devastating course of this epidemic can be attributed to biologic characteristics of the virus. It is more likely to be a result of the combination of dysfunctional health systems, international indifference, high population mobility, local customs, densely pop-ulated capitals, and lack of trust in authorities after years of armed conflict. Perhaps most im-portant, Ebola has reached the point where it could establish itself as an endemic infection be-cause of a highly inadequate and late global re-sponse. Not only did it take more than 3 months to diagnose Ebola as the cause of the epidemic (in contrast to the recent outbreak in the Demo-cratic Republic of Congo, where it took a matter of days), but it was not until 5 months and 1000 deaths later that a public health emergency was declared, and it was nearly another 2 months before a humanitarian response began to be put The New England Journal of Medicine Downloaded from nejm.org at LONDON SCH HYGIENE & TROPICAL MED on April 28, 2016. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. editorialn engl j med 371;16 nejm.org october 16, 20141546in place. It is not that the world did not know: Médicins sans Frontières, which has been spear-heading the response and care for patients with Ebola, has been advocating for a far greater re-sponse for many months. This epidemic, in other words, was an avoidable crisis, and as the Ebola Response Team’s article stresses, a prompt re-sponse to an emerging outbreak is critical in order to contain it before it becomes too vast in terms of both numbers of cases and geographic reach.The current Ebola epidemic highlights three transformations required in our approach to rap-idly emerging public health emergencies.First, in today’s world, it’s important to rec-ognize that if certain conditions are met — bio-logic shifts in a pathogen, changes in the inter-actions between humans and our environment, dysfunctional and underresourced health sys-tems, national and international indifference, lack of effective timely response, high popula-tion mobility, local customs that can exacerbate morbidity and mortality, spread in densely pop-ulated urban centers, and a lack of trust in au-thorities — what might once have been a limited outbreak can become a massive, nearly uncon-trollable epidemic.Second, classic “outbreak control” efforts are no longer sufficient for an epidemic of this size. Rather, what’s required is a large-scale, coordi-nated humanitarian, social, public health, and medical response, combining classic public health measures with safe and effective inter-ventions including behavioral changes, therapies, and when possible, vaccination. An appropriate response, moreover, requires an appreciation of the culture of the societies in the affected coun-tries and deployment of interventions with the population’s consent. Development of interven-tions in collaboration with the affected commu-nities and rebuilding of trust will be essential to their success. And these integrated efforts will need to be accompanied by much better coordi-nation and real-time, open sharing of informa-tion across diverse disciplines and with all the players involved, from civil society, national gov-ernments, nongovernmental organizations, and academic institutions to regional and international organizations and, when appropriate, the military.Third, the development of diagnostic tools, therapies, and vaccines (at least up through the ac-quisition of phase 1 safety data) for these relatively rare but inevitable and potentially devastating epidemic diseases must be prioritized during in-terepidemic periods, with an accepted, preap-proved, and ethical mechanism for accelerating development and testing such interventions when epidemic situations arise. We believe that in this epidemic, we are reaching the limit of what classic containment can achieve.Meanwhile, the current Ebola epidemic, which is in grave danger of spiraling out of control, must remain the primary focus of our efforts. We are concerned that without a massive increase in the response, way beyond what is being planned in scale and urgency, alongside the complementa-ry deployment of novel interventions (in particular the use of safe and effective vaccines and thera-peutics), it will prove impossible to bring this epidemic under control.But we must also look to the future. There will be more epidemics and outbreaks of Ebola and other new or reemerging infections. Yet our re-sponse to such events remains slow, cumbersome, poorly funded, conservative, and ill prepared. We have been very lucky with the severe acute respi-ratory syndrome (SARS), H5N1 and H1N1 influ-enza, and possibly the Middle East respiratory syn-drome coronavirus (MERS-CoV), but this Ebola epidemic shows what can happen when luck es-capes us. With a different pathogen and a differ-ent transmission route, a similar crisis could strike in New York, Geneva, and Beijing as easily as this one has in West Africa.Despite great improvement over the past dec-ade, there is still a need for better surveillance, sharing of data in real time, and rapid action based on the available information. But we can-not think that surveillance alone will bring such events under control. We have become better at picking these things up; we now must also learn to act more effectively.Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.From the Wellcome Trust ( J.J.F.) and the London School of Hy-giene and Tropical Medicine (P.P.) — both in London.This article was published on September 23, 2014, at NEJM.org.1. WHO Ebola Response Team. Ebola virus disease in West Africa — the first 9 months of the epidemic and forward projec-tions. N Engl J Med 2014;371:1481-95.DOI: 10.1056/NEJMe1411471Copyright © 2014 Massachusetts Medical Society.The New England Journal of Medicine Downloaded from nejm.org at LONDON SCH HYGIENE & TROPICAL MED on April 28, 2016. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. 

The Ebola emergency--immediate action, ongoing strategy.

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The Ebola emergency--immediate action, ongoing strategy.

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