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Ebola, forgotten but not gone

written by Dr. Stephen A. Berger, Dr. Yaakov Dickstein, and Edward Borton

The recent WHO decision to declare the novel coronavirus outbreak a Public Health Emergency of International Concern (PHEIC), while both appropriate and hardly surprising, offers the opportunity to reflect on the previous PHEIC which was declared, namely the Ebola epidemic in Kivu region, Democratic Republic of the Congo (DRC). And you should really say the ongoing Ebola epidemic, as during the time since the declaration in July 2019 through to the present day (March 2020), a total of 3,453 cases have been reported [1].

The nCoV-2019 outbreak is still ballooning; as of today, over 400,000 confirmed cases worldwide with no signs of slowing down [2]. To date, there have been 19,786 fatalities, a mortality rate which is notably higher than the rate observed in the 2018-9 influenza pandemic (>2.5%) and significantly higher than AH1N1 (~0.05%) [3,4]. As you might have hoped, the response has been incredibly rapid, faster than ever seen before with a new human pathogen. Within weeks of identifying an outbreak of respiratory illness, the virus has been identified, sequenced and cultured; rapid tests are available for diagnosis (albeit with continuing broadening and narrowing); at least two randomized controlled trials (RCTs) are being performed to analyze the effect of antiviral medications, one with a new drug; and the largest infection control effort in history is underway, including the quarantine of more than 50 million inhabitants in Hubei province, China [5]. Internationally, airlines have ceased operating to China; large-scale surveillance of suspected patients and their contacts is being performed around the clock, and naturally, the media response has been extensive. It would prove more difficult to find someone who didn’t know of the new coronavirus than someone unaware.

The history of Ebola is different, both in impact and response. Ebola is vicious; out of 3,453 cases confirmed since the beginning of the current outbreak, 2264 or 66% have died, similar to ratios from previous outbreaks and among the highest case fatality rates of any human pathogen [1]. First isolated in 1976 following separate outbreaks in Sudan and what was then Zaire, there have been numerous outbreaks of Ebola since, both small and large, however scientific and media attention was limited for the first 20 years. An average of just 9 yearly publications related to the virus was published between 1977-1994 and it was only in 1995, when a major outbreak occurred in DRC, that interest began to be generated [6]. Coincidentally, the movie ‘Outbreak’, released just two months before the first cases in the DRC, also served to increase public awareness of the disease. It was the 2014-6 epidemic, however, which displayed the epidemic potential of the disease, with nearly 30000 suspected cases and more than 11000 fatalities [7]. The declaration of a PHEIC and a global response followed, including the use of experimental antiviral treatment and vaccination. Nevertheless, it took two years before the epidemic terminated.

It may well be an inconvenient truth that the responsiveness to any outbreak will be based on the impact on Western society, chiefly the economy, rather than the severity of the illness and endangerment to human life and well-being. Notwithstanding the vast amount of funds the global economy generates for medical research and treatment production, a more consistent global approach to tackling both the outbreaks themselves and managing awareness and attention would give less developed countries a better platform to address the events in a timely manner, minimizing the risk of extreme outcomes.

Thankfully the current outbreak has been less explosive than that of 2014-6, which could explain, if not forgive, the correspondingly tepid response; while organizations such as Médecins Sans Frontières (MSF, Doctors Without Borders) have been on the front lines from the beginning, it took the WHO four reviews of its original negative decision before they announced a PHEIC. Unfortunately, the situation has been complicated considerably by an ongoing conflict, which has escalated to actively target healthcare workers, including 386 attacks with 77 injured and 7 dead in 2019 [8]. Nevertheless, work has continued and has borne fruit and new cases of Ebola have declined significantly during the current outbreak since the end of September 2019, with only one newly-confirmed case this past week and hopefully, an end is close [1].

Outside of any political or economic reason, it is perhaps human nature to be attracted and fascinated in that which is new and shrouded in mystery and misinformation, and it is seemingly appropriate that the word “novel” (from Latin Novus, “new” or “fresh”) has been incorporated into the name of the virus which now makes the headlines. All the same, the fact that a public health emergency is currently of less international import or concern does not make it any less important or pressing, especially to the locals and health care workers fighting the illness. Given the WHO saw fit to label it as such an emergency, it should also see fit to continue rendering assistance proportionate to that description until the emergency is completely over and the region free from further risk; otherwise why have such labels at all?

Read more on the global status of Ebola

  1. https://www.who.int/emergencies/diseases/ebola/drc-2019. Accessed 3rd March 2020
  2. https://coronavirus.jhu.edu/map.html. Accessed 11th March.2020
  3. Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. Emerg Infect Dis 2006 Jan;12(1):15-22
  4. Nishiura H. The virulence of pandemic influenza A (H1N1) 2019: an epidemiological perspective on the case-fatality ratio. Expert Rev Respir Med. 2010 Jun;(4)3:329-38
  5. See ProMED string for Novel coronavirus at https://promedmail.org/
  6. Pubmed search for “Ebola”, performed 6.2.2020. https://www.ncbi.nlm.nih.gov/pubmed
  7. WHO Ebola virus disease fact sheet. https://www.who.int/en/news-room/fact-sheets/detail/ebola-virus-disease. Accessed 6.2.2020.
  8. https://www.scientificamerican.com/article/ebola-response-workers-killed-in-attacks-force-withdrawal-from-critical-drc-region/. Accessed 6.2.2020.

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