BMC Medical Ethics
(Accessed 18 October2014)
http://www.biomedcentral.com/bmcmedethics/content

Research article
Ethical issues in the export, storage and reuse of human biological samples in biomedical research: perspectives of key stakeholders in Ghana and Kenya
Paulina Tindana, Catherine S Molyneux, Susan Bull and Michael Parker
Author Affiliations
BMC Medical Ethics 2014, 15:76 doi:10.1186/1472-6939-15-76
Published: 18 October 2014
Abstract (provisional)
Background
For many decades, access to human biological samples, such as cells, tissues, organs, blood, and sub-cellular materials such as DNA, for use in biomedical research, has been central in understanding the nature and transmission of diseases across the globe. However, the limitations of current ethical and regulatory frameworks in sub-Saharan Africa to govern the collection, export, storage and reuse of these samples have resulted in inconsistencies in practice and a number of ethical concerns for sample donors, researchers and research ethics committees. This paper examines stakeholders’ perspectives of and responses to the ethical issues arising from these research practices.
Methods
We employed a qualitative strategy of inquiry for this research including in-depth interviews and focus group discussions with key research stakeholders in Kenya (Nairobi and Kilifi), and Ghana (Accra and Navrongo).
Results
The stakeholders interviewed emphasised the compelling scientific importance of sample export, storage and reuse, and acknowledged the existence of some structures governing these research practices, but they also highlighted the pressing need for a number of practical ethical concerns to be addressed in order to ensure high standards of practice and to maintain public confidence in international research collaborations. These concerns relate to obtaining culturally appropriate consent for sample export and reuse, understanding cultural sensitivities around the use of blood samples, facilitating a degree of local control of samples and sustainable scientific capacity building.
Conclusion
Drawing on these findings and existing literature, we argue that the ethical issues arising in practice need to be understood in the context of the interactions between host research institutions and local communities and between collaborating institutions. We propose a set of ‘key points-to-consider’ for research institutions, ethics committees and funding agencies to address these issues.

British Medical Journal
18 October 2014(vol 349, issue 7979)
http://www.bmj.com/content/349/7979

Editor’s Choice
Ebola: will enlightened self interest spur us to act?
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6254 (Published 16 October 2014) Cite this as: BMJ 2014;349:g6254
Fiona Godlee, editor in chief, The BMJ
More than 4400 people are now reported to have died in the Ebola epidemic in west Africa (doi:10.1136/bmj.g6255), and the US Centers for Disease Control has estimated that as many as 1.4 million people may be infected by the end of January. Fatality rates are reported to be around 50%. Health infrastructure in the three worst affected countries was already struggling but is now close to total collapse. The limited ranks of trained healthcare workers have been decimated by disease, exhaustion, and fear. Almost 200 healthcare workers are known to have died.

The head of the charity Médecins Sans Frontières, Joanne Liu, describes the desperate situation in an interview with The BMJ published this week: “Local doctors have been extremely brave, but we are running out of staff” (doi:10.1136/bmj.g6151). And she herself is “running out of words to convey the sense of urgency.” She acknowledges that the capacity of rich nations to respond to distant crises has been stretched like never before in recent months. This year MSF has deployed more staff in more countries than ever before.

What we now need are well trained and well equipped boots on the ground. Liu wants to see bioterrorism teams that countries set up after 9/11 to be deployed to fight Ebola. Countries with historical links to the region, mainly the United States and United Kingdom, are sending (or promising) troops to set up treatment centres. This week Andy Johnston and Mark Bailey describe Operation Gritrock, which has just sent British army medics to Sierra Leone to set up a treatment centre for health workers (doi:10.1136/bmj.g6237). But the response of other countries, Liu says, has been slower and hands off. “Everyone is looking for excuses not to deploy because they are so scared,” she says.

Perhaps the only real hope for spurring capable countries into action is enlightened self interest. So the fact that the United Nations Security Council has declared the outbreak a threat to international peace and security should help. So too should the now real threat of spread of the disease beyond west Africa. But so far screening at airports is almost the only result (doi:10.1136/bmj.g6199; doi:10.1136/bmj.g6147). This may be reassuring to travellers and citizens, but our editorialists David Mabey and colleagues say it is false reassurance and a waste of money (doi:10.1136/bmj.g6202). Previous experience from the severe acute respiratory syndrome (SARS) epidemic should have told us this, they say. Airport screening for SARS in Canada cost $C17m (£9m; €12m; $15m) and identified not a single case.

Mabey and colleagues have done the sums for Ebola. With an incubation period of 21 days—and assuming that people who want to make the journey may hide symptoms and signs—screening to prevent people boarding flights is likely to fail, and screening on entry to a country will have “no meaningful effect on the risk of importing Ebola.” Far better, they say, to provide clear information to those who may be at risk on how and where to seek care. This would be as effective as screening at a fraction of the cost. In a letter this week Sunday Oluwafemi Oyeyemi and colleagues confirm the need for clear and accurate information on how to prevent and treat Ebola infection (doi:10.1136/bmj.g6178). Their review of information shared on Twitter within affected countries shows a high prevalence of misleading information, some of which, such as the advice to drink salty water, is known to have killed people. Governments should use Twitter to spread correct information and amend misinformation, they say.

Liu and MSF have been the voice of absolute humanitarian ideals. Many health professionals and military personnel will, as individuals, rise to that same level of moral courage. For the rest, enlightened self interest is not so bad and is better than nothing. But let’s spend our resources on the right things. Not airport checks but, as Mabey and colleagues conclude, immediate scaling up of our presence in west Africa, building new treatment centres at a rate that outstrips the epidemic. This would not only help the people in affected countries but reduce the risk of the Ebola virus spreading elsewhere.

Editorials
Airport screening for Ebola
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6202 (Published 14 October 2014) Cite this as: BMJ 2014;349:g6202
David Mabey, professor, Stefan Flasche, lecturer, W John Edmunds, professor
Author affiliations
Will it make a difference?
On 9 October the UK government announced that “enhanced screening” for Ebola virus disease will be implemented at Heathrow and Gatwick airports and Eurostar terminals. Details of how this will be done are not yet available, but the objectives presumably are to identify people arriving from Sierra Leone, Guinea, or Liberia who may have been exposed to Ebola, assess whether they have symptoms consistent with Ebola, test those who do, and isolate anyone with positive results.

Several practical difficulties will need to be overcome to achieve these objectives. As most direct flights to the UK from Sierra Leone, Guinea, and Liberia have been discontinued because of the epidemic, passengers will be arriving from various European cities, and itineraries will need to be carefully checked to identify passengers arriving from those countries. Those who are identified will be asked to complete a questionnaire stating whether they have been in contact with sick people or have attended funerals in west Africa, and whether they have symptoms such as fever, headache, diarrhoea, or vomiting. People who answer “yes” to any of these questions will presumably be referred to a health official, which is likely to lead to considerable delays; this would not be an incentive to fill in the form honestly. A thermal scanning device may also be used to check passengers’ temperature on arrival, but it is unclear what will happen to those found to have a fever. Most will not have Ebola. Even if testing facilities are on site, substantial delays to large numbers of passengers seem inevitable, and isolation of all passengers waiting for their test results may prove challenging.

The World Health Organization recommends that passengers on international flights out of Sierra Leone, Guinea, and Liberia should be screened for evidence of Ebola before boarding their flight. Those with symptoms or a raised temperature should not be allowed on the flight. Clearly, identifying people with Ebola before they board an international flight is a desirable objective. But how well does this system work in practice? Data are not available on the number of passengers denied entry to a flight during the current epidemic, but there are strong incentives for those wishing to fly to deny symptoms even if they have them and to take an antipyretic such as aspirin to bring down their temperature if they have a fever.

Lack of evidence
Is there any evidence that screening travellers arriving at international airports is an effective way of identifying those with serious infections? The data from Canada, which introduced airport screening during the SARS (severe acute respiratory syndrome) epidemic, are not encouraging. A total of 677 494 people arriving in Canada returned completed questionnaires, of whom 2478 answered “yes” to one or more question. A specially trained nurse referred each of these for in-depth questioning and temperature measurement; none of them had SARS. Thermal scanners were installed at six major airports. Of the 467 870 people screened, 95 were referred to a nurse for further assessment. None of them was confirmed to have a raised temperature. The cost of this unsuccessful programme was $CA17m (£9m; €12m; $15m).1

Why was this measure so ineffective, and could it work now? During the SARS epidemic a simple model was used to assess the fraction of cases that could be detected by entrance screening.2 Assuming that people with symptoms are not allowed to board, entrance screening can only pick up those who develop symptoms while travelling. The longer the incubation period in relation to the flight duration, the lower the chance that this will happen, and the lower the yield from entrance screening. Updating the model using data on Ebola (incubation time 9.1±7.3 days3; direct flight from Freetown to London 6.42 hours), we estimate that, if everyone with symptoms was denied boarding,about 7 out of 100 people infected with Ebola travelling to the UK would have symptoms on arrival and hence be detectable by entrance screening (95% confidence interval 3 to 13). The other 93% would enter the UK unimpeded. If passengers arriving via Paris or Brussels (journey time about 13 hours) were not screened in transit, entrance screening in the UK could detect up to 13% of infected people (95% CI 7% to 21%). The majority would still enter the UK before developing symptoms. Only if patients are allowed to fly irrespective of symptoms would entrance screening be able to detect a substantial fraction of cases (43% if there is no direct flight, 95% CI 34% to 53%).

People who know they are at risk and develop symptoms will want to seek care immediately, as they will fear for their lives. The priority should be to provide information to all those who may be at risk on how and where to seek care. This would be as effective as screening at a fraction of the cost.

Adopting the policy of “enhanced screening” gives a false sense of reassurance. Our simple calculations show that an entrance screening policy will have no meaningful effect on the risk of importing Ebola into the UK. Better use of the UK’s resources would be to immediately scale-up our presence in west Africa—building new treatment centres at a rate that outstrips the epidemic, thereby averting a looming humanitarian crisis of frightening proportions. In so doing, we would not only help the people of these affected countries but also reduce the risk of importation to the UK.
Research
Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial
Orazio P Attanasio, Jeremy Bentham chair of economics1, Camila Fernández, senior survey researcher2, Emla O A Fitzsimons, professor of economics3, Sally M Grantham-McGregor, emerita professor of international child health4, Costas Meghir, Douglas A Warner III professor of economics5, Marta Rubio-Codina, senior research economist6
Author affiliations
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5785 (Published 29 September 2014) Cite this as: BMJ 2014;349:g5785
Abstract
Objective
To assess the effectiveness of an integrated early child development intervention, combining stimulation and micronutrient supplementation and delivered on a large scale in Colombia, for children’s development, growth, and hemoglobin levels.
Design
Cluster randomized controlled trial, using a 2×2 factorial design, with municipalities assigned to one of four groups: psychosocial stimulation, micronutrient supplementation, combined intervention, or control.
Setting
96 municipalities in Colombia, located across eight of its 32 departments.
Participants 1420 children aged 12-24 months and their primary carers.
Intervention Psychosocial stimulation (weekly home visits with play demonstrations), micronutrient sprinkles given daily, and both combined. All delivered by female community leaders for 18 months.
Main outcome measures
Cognitive, receptive and expressive language, and fine and gross motor scores on the Bayley scales of infant development-III; height, weight, and hemoglobin levels measured at the baseline and end of intervention.
Results
Stimulation improved cognitive scores (adjusted for age, sex, testers, and baseline levels of outcomes) by 0.26 of a standard deviation (P=0.002). Stimulation also increased receptive language by 0.22 of a standard deviation (P=0.032). Micronutrient supplementation had no significant effect on any outcome and there was no interaction between the interventions. No intervention affected height, weight, or hemoglobin levels.
Conclusions
Using the infrastructure of a national welfare program we implemented the integrated early child development intervention on a large scale and showed its potential for improving children’s cognitive development. We found no effect of supplementation on developmental or health outcomes. Moreover, supplementation did not interact with stimulation. The implementation model for delivering stimulation suggests that it may serve as a promising blueprint for future policy on early childhood development.
Feature
Only the military can get the Ebola epidemic under control: MSF head
BMJ 2014;349:g6151 (Published 10 October 2014)
PDF
Operation Gritrock: first UK army medics fly to Sierra Leone
BMJ 2014;349:g6237 (Published 14 October 2014)
PDF

Globalization and Health
[Accessed 18 October2014]
http://www.globalizationandhealth.com/

Commentary
Accreditation as a path to achieving universal quality health coverage
Kedar S Mate1*, Anne L Rooney1, Anuwat Supachutikul2 and Girdhar Gyani3
Author Affiliations
1 Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge 02138, MA, USA
2 Healthcare Accreditation Institute, Bangkok, Thailand
3 National Accreditation Board for Hospitals and Healthcare Providers, New Delhi, India
Globalization and Health 2014, 10:68 doi:10.1186/s12992-014-0068-6
Abstract
As many low- and middle-income countries (LMICs) pursue health care reforms in order to achieve universal health coverage (UHC), development of national accreditation systems has become an increasingly common quality-enhancing strategy endorsed by payers, including Ministries of Health. This article describes the major considerations for health system leaders in developing and implementing a sustainable and successful national accreditation program, using the 20-year evolution of the Thai health care accreditation system as a model. The authors illustrate the interface between accreditation as a continuous quality improvement strategy, health insurance and other health financing schemes, and the overall goal of achieving universal health coverage

Health and Human Rights
Volume 16, Issue 2 December 2014
http://www.hhrjournal.org/

Papers in Press: Special Issue on Health Rights Litigation
The following papers are accepted for publication in the forthcoming Special Issue on Health Rights Litigation, guest edited by Alicia Ely Yamin.

Editorial
Promoting Equity in Health: What Role for Courts?
Alicia Ely Yamin

In Memoriam
Giulia Tamayo, 1958-2014
Alicia Ely Yamin

Selected Articles
Sanitation Rights, Public Law Litigation, and Inequality: A Case Study from Brazil
Ana Paula de Barcellos

Health Rights in the Balance: The Case Against Perinatal Shackling of Women Behind Bars
Brett Dignam and Eli Y. Adashi

Litigating the Right to Health: What Can We Learn from a Comparative Law and Health Care Systems Approach
Colleen M. Flood and Aeyal Gross

Striking a Balance: Conscientious Objection and Reproductive Health Care from the Colombian Perspective
Luisa Cabal, Monica Arango Olaya, and Valentina Montoya Robledo

Health Rights Litigation and Access to Medicines: Priority Classification of Successful Cases from Costa Rica’s Constitutional Chamber of the Supreme Court
Ole Frithjof Norheim and Bruce M. Wilson

The Lancet
Oct 18, 2014 Volume 384 Number 9952 p1401 – 1476
http://www.thelancet.com/journals/lancet/issue/current

Comment
Controlling Ebola: next steps
Ranu S Dhillon, Devabhaktuni Srikrishna, Jeffrey Sachs
Preview |
The Ebola epidemic is paradoxical: it is out of control yet readily controllable. The key to epidemic control is rapid diagnosis, isolation, and treatment of infected individuals.1 This approach was used in past Ebola outbreaks through contact tracing, in which anyone exposed to a person with Ebola was monitored, tested if they developed symptoms, and, if positive, securely transported to a health facility for treatment.2 Moreover, while 60–90% of untreated patients with Ebola die, effective medical care could reduce this rate to below 30%.

Nature
Volume 514 Number 7522 pp273-398 16 October 2014
http://www.nature.com/nature/current_issue.html

Ebola by the numbers: The size, spread and cost of an outbreak
As the virus continues to rampage in West Africa, Nature’s graphic offers a guide to the figures that matter.
Declan Butler & Lauren Morello

15 October 2014
Nature | Comment
Ebola: learn from the past
David L Heymann
09 October 2014
Drawing on his experiences in previous outbreaks, David L. Heymann calls for rapid diagnosis, patient isolation, community engagement and clinical trials.

New England Journal of Medicine
October 16, 2014 Vol. 371 No. 16
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Achieving and Maintaining Polio Eradication — New Strategies
John Modlin, M.D., and Jay Wenger, M.D.
N Engl J Med 2014; 371:1476-1479 October 16, 2014
DOI: 10.1056/NEJMp1407783

It has been nearly 2 years since the last known case of type 3 poliomyelitis occurred in Nigeria, and although it’s still too early to celebrate, the disappearance of the second of the three poliovirus serotypes (type 2 transmission was eliminated in 1999) represents a major milestone and proof of principle that global eradication of paralytic poliomyelitis is achievable.

Poliovirus transmission has been identified in 10 countries this year, but more than 75% of the cases have occurred in Pakistan, where antigovernment militants have denied immunization to more than 300,000 children for more than 2 years. This summer, military activities opened some areas to vaccination teams and provided an opportunity to deliver oral polio vaccine (OPV) with other basic health services to displaced children and families, while also creating a risk of dispersal of poliovirus-infected persons more broadly in the region. Multiple supplemental immunization rounds are targeting the other countries with recent transmission of type 1 poliovirus and additional countries that are at risk for reinfection. Given the substantial progress in Nigeria and the small number of polio cases identified elsewhere in Africa in recent months, it is now possible that the continent will be free of polio by the end of the year.

The past decade has brought new partners to the Global Polio Eradication Initiative (GPEI) consortium, new tools for improving immunization and surveillance, a new sense of urgency about completing eradication, and confidence that such a feat is possible. Several factors are making a difference: improvements in planning for supplementary immunization activities, support for delivering other key health interventions through the polio program, innovations such as global-positioning-system mapping, and strategies including the establishment of immunization stations at transit points and the engagement of government, traditional, and religious leaders at all levels. To further reduce the risk of international exportation of polio from countries where it is endemic — exportation accounted for 60% of all polio cases in 2013 — the World Health Organization (WHO) recently designated polio as a public health emergency of international concern under the International Health Regulations and recommended that travelers leaving any country with active transmission receive additional immunization.

As the areas with sustained polio transmission shrink and the genetic diversity of the remaining type 1 polioviruses narrows, global public health authorities are preparing for a phased transition from the live, attenuated OPV to the inactivated polio vaccine (IPV) originally introduced in 1955. Although it may appear counterintuitive to replace OPV, a cheap vaccine easily administered in two oral drops, with IPV, which is at least 10 times as expensive to produce and is given by injection, discontinuation of OPV has always been a component of polio-eradication plans because of the occurrence of vaccine-associated paralytic poliomyelitis in a very small proportion of OPV recipients (<1 per 750,000 recipients in the United States, for example).

There are two additional challenges that make the switch from OPV to IPV necessary, neither of which was anticipated when the World Health Assembly launched the GPEI in 1988. The first is the magnitude of reduced effectiveness of OPV in locations with a high burden of enteric pathogens and diarrheal disease. This limitation can be striking, with seroconversion rates of less than 20% per dose of trivalent OPV (tOPV) in some locations, which leave many children who have received multiple doses still susceptible to polio. The elimination of naturally occurring type 2 polioviruses allowed for a partial solution to this problem: deployment in supplementary immunization activities of monovalent type 1 vaccine (mOPV1) and bivalent types 1 and 3 vaccine (bOPV), which induced improved immune responses to type 1 and type 3 polioviruses by removing the interfering type 2 OPV viruses from the formulation.

The second problem was uncovered with the development of viral genetic sequencing technology, which revealed that OPV viruses can regain fitness and neurovirulence with continuous person-to-person transmission in areas of low population immunity. Circulating vaccine-derived polioviruses (cVDPVs) were first recognized on Hispaniola in 2000 and have since caused outbreaks and isolated cases of paralytic disease from viruses of all three serotypes in multiple locations. The existence of cVDPVs dictates that all OPV use will need to cease in order to achieve full polio eradication.
A GPEI strategic plan for 2013 through 2018 envisions the complete cessation of circulation of wild-type poliovirus and VDPV followed by coordinated replacement of tOPV with bOPV for an interim period to prevent the generation of new type 2 cVDPVs, which have been responsible for virtually all emergences of VDPV during the past 5 years. The plan calls for the eventual discontinuation of OPV use once eradication of all types is achieved.
However, mathematical models suggest that the global risk of cVDPV reemergence from residual OPV type 2 circulation will be substantial in the first 1 to 3 years after OPV type 2 cessation.1 To mitigate this risk, the WHO Strategic Advisory Group of Experts on immunization has recommended that all countries that use OPV add at least one IPV dose to the routine immunization of infants in advance of the tOPV–bOPV switch, currently planned for 2016. The recommendation is based on affordability, the ability of a single vaccine dose to prime the immune system to respond to another dose administered during an outbreak, and the likelihood that one dose will moderately reduce the risk of disease among vaccinated children in the event of type 2 cVDPV exposure (one-dose seroconversion would be expected in 40 to 50% of recipients). This strategy enhances immunity to types 1 and 3 in two ways: by improving the immunogenicity of OPV with the removal of type 2 vaccine virus and by enhancing immunity in children who are given both bOPV and IPV during routine infant immunization.2
Two recent studies in India have shown that IPV administered to children previously given OPV boosts both humoral neutralizing-antibody levels and intestinal mucosal immunity.3,4 Attention to intestinal immunity has increased because of uncertainty about the extent to which polio may circulate in populations with only IPV-induced immunity. Unlike primary immunization with OPV, primary immunization with IPV provides only marginal intestinal immunity, as measured by poliovirus excretion after OPV challenge.5 Outbreaks of wild-type poliovirus have been adequately contained in the Netherlands and other developed countries that use only IPV for routine childhood immunization. However, recent experience in Israel with prolonged circulation of type 1 polioviruses in sewage effluents has generated substantial concern that IPV-induced intestinal immunity may not prevent silent transmission in developing countries despite high immunization rates and that infection could spread extensively before the first clinical case is detected.
In that event, the only realistic approach to control of the outbreak would be widespread immunization of the at-risk population with OPV or a combination of IPV and OPV. But either option requires creating a risk of downstream cVDPV, threatening final eradication. To better prepare for this possible threat, the Bill and Melinda Gates Foundation is supporting the development and clinical evaluation of new genetically stable OPV strains with reduced ability to genetically revert to cVDPVs.

Although our current optimism must be tempered by the tendency of polio to emerge in areas of armed conflict and humanitarian crisis where routine immunization systems have collapsed and it’s difficult to gain access to susceptible children, more of the world’s population than ever is living in certified polio-free regions, and we are inexorably approaching the end of polio. Key strategic components of the endgame plan, including the tOPV–bOPV switch and introduction of affordable IPV, are focused on the final obstacles to eradication. Development of improved vaccines will provide additional confidence that eradication can be sustained.

New England Journal of Medicine
October 16, 2014 Vol. 371 No. 16
http://www.nejm.org/toc/nejm/medical-journal

Editorial
The Ebola Emergency — Immediate Action, Ongoing Strategy
Jeremy J. Farrar, M.D., Ph.D., and Peter Piot, M.D., Ph.D.
N Engl J Med 2014; 371:1545-1546 October 16, 2014 DOI: 10.1056/NEJMe1411471
The 25th known outbreak of Ebola virus infection 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 profound 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 disease, and mental health during and after the Ebola epidemic. Indeed, there is a very real danger 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 completeness 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 outbreak, the clinical manifestations of Ebola virus disease, the duration of illness, the case fatality rate, and the degree of transmissibility are similar 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 populated capitals, and lack of trust in authorities after years of armed conflict. Perhaps most important, Ebola has reached the point where it could establish itself as an endemic infection because of a highly inadequate and late global response. 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 Democratic 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 in place. It is not that the world did not know: Médicins sans Frontières, which has been spearheading the response and care for patients with Ebola, has been advocating for a far greater response for many months. This epidemic, in other words, was an avoidable crisis, and as the Ebola Response Team’s article stresses, a prompt response 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 rapidly emerging public health emergencies.
First, in today’s world, it’s important to recognize that if certain conditions are met — biologic shifts in a pathogen, changes in the interactions between humans and our environment, dysfunctional and underresourced health systems, national and international indifference, lack of effective timely response, high population mobility, local customs that can exacerbate morbidity and mortality, spread in densely populated urban centers, and a lack of trust in authorities — what might once have been a limited outbreak can become a massive, nearly uncontrollable epidemic.
Second, classic “outbreak control” efforts are no longer sufficient for an epidemic of this size. Rather, what’s required is a large-scale, coordinated humanitarian, social, public health, and medical response, combining classic public health measures with safe and effective interventions including behavioral changes, therapies, and when possible, vaccination. An appropriate response, moreover, requires an appreciation of the culture of the societies in the affected countries and deployment of interventions with the population’s consent. Development of interventions in collaboration with the affected communities and rebuilding of trust will be essential to their success. And these integrated efforts will need to be accompanied by much better coordination and real-time, open sharing of information across diverse disciplines and with all the players involved, from civil society, national governments, 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 acquisition of phase 1 safety data) for these relatively rare but inevitable and potentially devastating epidemic diseases must be prioritized during interepidemic periods, with an accepted, preapproved, 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 complementary deployment of novel interventions (in particular the use of safe and effective vaccines and therapeutics), 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 response to such events remains slow, cumbersome, poorly funded, conservative, and ill prepared. We have been very lucky with the severe acute respiratory syndrome (SARS), H5N1 and H1N1 influenza, and possibly the Middle East respiratory syndrome coronavirus (MERS-CoV), but this Ebola epidemic shows what can happen when luck escapes us. With a different pathogen and a different 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 decade, there is still a need for better surveillance, sharing of data in real time, and rapid action based on the available information. But we cannot 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.