Ebola virus epidemic in West Africa

The Ebola virus epidemic in West Africa was an epidemic of Ebola virus disease (EVD) in certain West African countries primarily occurring from 2013 to 2016. is the most severe outbreak of Ebola since the discovery of ebolaviruses in 1976, and by September 2014 cases of EVD from this single outbreak exceeded the sum of all previously identified cases.

The epidemic began in Guinea in December 2013 then spread to Liberia and Sierra Leone. Much smaller subsidiary outbreaks have also occurred in Senegal and Nigeria, and individual cases have occurred in the United States and Spain. As of October 2014, the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC) and local governments reported a total of 8,033 suspected cases and 3,866 deaths (4,462 cases and 2,330 deaths having been laboratory confirmed), though the WHO believes that this substantially understates the magnitude of the outbreak. The epidemic has caused significant mortality, with a Case Fatality Rate (CFR) reported as 71%.

Quotes

• Fabian Leendertz, a veterinarian at the Robert Koch Institute in Berlin, will bring his expertise in spillover events. In April 2014, Leendertz visited Meliandou village in Guinea, months after a two-year-old died of Ebola — the first person reported to be infected in West Africa.
  Work by Leendertz, including interviews with locals and environmental sampling, suggests that the outbreak started in bats that lived in a hollow tree where the children used to play. The tree was burned down days before his arrival and no Ebola virus was detected in nearby bats, which he says highlights the difficulties of pinning down an outbreak’s beginnings.
  • Smriti Mallapaty, “Meet the scientists investigating the origins of the COVID pandemic”, Nature, (02 December 2020), 588, p.208

• When Ebola ripped through communities in West Africa between 2014 and 2016, Tolbert Nyenswah saw at first hand how health workers extinguished the epidemic by finding and quarantining contacts of those who caught the disease. The former director of Liberia’s public-health institute thought contact-tracers would again rise to the challenge this year, keeping COVID-19 in check as it swept the globe. “Contact-tracing is one of the greatest tools that countries should deploy and use effectively to contain the outbreak,” he says.
  • Tolbert Nyenswah as quoted in “Why many countries failed at COVID contact-tracing — but some got it right”, by Dyani Lewis, Nature, (14 December 2020; correction 17 December 2020), 588, pp.384-387

• At the moment, our big problem is finding the patients in a timely way and convincing them to come to the treatment center. If you don’t have a carrot to hang out there and bring people in, then you can’t contain it.
  • Dr. Armand Sprecher, a public health specialist for the aid group Doctors Without Borders, quoted by the New York Times
  • Regarding issues with potentially infected persons being suspicious of health care in general and not seeking treatment while also posing the risk of spreading the infection.

• West Africa is experiencing the largest, most severe, most complex outbreak of Ebola virus disease in history.
  • World Health Organization, "Ethical considerations for use of unregistered interventions for Ebola viral disease"

• The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long.
  • World Health Organization, Ebola situation assessment - 26 September 2014
  • Note: Biosafety level 4 is the highest of four biosafety levels, indicating that an agent poses a high individual risk of aerosol-transmitted laboratory infections or causea severe to fatal disease in humans for which vaccines or other treatments are not available.

• [The WHO panel] concluded unanimously that it would be acceptable on both ethical and evidential grounds to use as potential treatments or for prevention unregistered interventions that have shown promising results in the laboratory and in animal models but have not yet been evaluated for safety and efficacy in humans, provided that certain conditions are met. In reaching these conclusions, the panel members were mindful that this is a departure from the well-established, historically evolved system of regulation and governance of therapies and interventions. Ethical and scientific criteria must guide the use of unregistered interventions. The ethical criteria include transparency about all aspects of care, so that maximum information is obtained about the effects of the interventions, fair distribution in the face of scarcity, promotion of cosmopolitan solidarity, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community.
  • World Health Organization, "Ethical considerations for use of unregistered interventions for Ebola viral disease"
  • On 11 August 2014, WHO brought together an advisory panel "to consider and assess the ethical implications for clinical decision-making of use of unregistered interventions that have shown promising results in the laboratory and in animal models but that have not yet been evaluated for safety and efficacy in humans." The panel convened after such an intervention (ie.medication) was given with positive results to two infected American healthcare workers, raising ethical concerns about who should receive the limited doses of experimental drugs, such as ZMapp, TKM-Ebola, & VSV-EBOV.

ZMapp

• You’ve got to balance the compassionate-use aspect with trying to figure out whether it works.
  • Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health, quoted by the New York Times.

• I'd say we have a couple of people who've recovered, they've gotten excellent medical care and the specific therapy, ZMapp … may have had a role in it but we don't know.
  • Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health, quoted by Reuters

• It would have been the front-page screaming headline: ‘Africans used as guinea pigs for American drug company’s medicine’
  • Dr. Salim S. Abdool Karim, director of Caprisa (an AIDS research center in South Africa), quoted by the New York Times
  • Regarding the ethics of providing a drug never before used in humans to Africans. The first patients to receive the drug, of which only a few doses were available, were white, Western healthcare workers, which has caused some controversy.

• I think that this is very unfortunate for perceptions of global justice.
  • Lawrence Gostin, university professor and director of the O'Neill Institute for National and Global Health Law at Georgetown University Law School, quoted by USA Today
  • Regarding the ethics of providing the first few doses of the experimental drug, of which only a few doses were available, to white, Western healthcare workers, which has caused some controversy.

• Some people look at the word 'expedited' as very favorable. Who wouldn't want something expedited? It can be very hard to say that's not a good thing to do. But history says a lot of time when we rush things through, people are harmed.
  • Dr. Samuel Packer, chair of the ethics committee at North Shore University Hospital in Manhasset, New York, quoted by WebMD
  • Responding to calls to expedite production and approval of ZMapp

• You really worry how people in a vulnerable population will understand the risks. Do you think you can give informed consent, or are you likely to be coercive? How would I explain the risk of a brand-new drug to an African patient?
  • Dr. Samuel Packer, chair of the ethics committee at North Shore University Hospital in Manhasset, New York, quoted by WebMD
  • Regarding the ethics of providing the first few doses of the experimental drug, of which only a few doses were available, to white, Western healthcare workers, which has caused some controversy.

• What if it had killed both of them? It is only because it worked, seemingly very well, that people are screaming, 'How come people in Africa didn't get it?'If the first people (to receive doses of ZMapp) would have been Liberian, headlines would have screamed, 'Experimental drug tested on poor Africans,'
  • Paul Root Wolpe, director of the Center for Ethics at Emory University, quoted by CNN
  • Regarding the ethics of providing the first few doses of the experimental drug, of which only a few doses were available, to white, Western healthcare workers, which has caused some controversy.

Surviving Ebola

Episode of NOVA which first aired on PBS on 8 October 2014.

[Discussing the decision to administer ZMapp to humans. ZMapp had previously been tested on monkeys with a 100% cure rate, but it was not planned to be tested in humans. Giving the limited doses of the drug to Western doctors as opposed to Africans has raised ethical concerns]

Gary Kobinger: My first reflex, and this is what I did, I warned against the unknown safety status of the drug...There were a lot of ethical questions, you know, why them? Why not the kids I've seen dying in front of me? You know, but you feel at one point that you have to stand or you have to step aside and at that time I thought...the right thing to do was step aside." (36:30-37:03)

Narrator: And everyone concerned had to weigh the risks of taking the medication against an unknown benefit. A decision had to be made and fast. (37:03-37:13)

Dr.John Fankhauser: My rationale for offering the drug was that, as a group of medical providers, with all of the medical information that we had, we had the feeling that it had a very high probability of being of value to Kent & Nancy. And then the decision to give the medications was really made after a discussion with Kent and Nancy and after they expressed their interest in getting the medication. (37:13-37:47)

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Dr.John Fankhauser: If these medications were given to an African by a team that was of a different culture and of a different background and that would have led to a bad outcome, we would have been harshly criticized. I think this was a time where we could offer these medications with true informed consent. Now, that being said, I am a complete believer that we need to strive for equity in this outbreak—that Africans should have access to the medications that are available to expatriates. (43:25-44:05)

Dr.John Fankhauser: If these medications were given to an African by a team that was of a different culture and of a different background and that would have led to a bad outcome, we would have been harshly criticized. I think this was a time where we could offer these medications with true informed consent. Now, that being said, I am a complete believer that we need to strive for equity in this outbreak—that Africans should have access to the medications that are available to expatriates. (43:25-44:05).