Ebola – humanitarian tragedy on monumental scale

PROF BARRY SCHOUB

Soon after, the UN Security Council, on reviewing the unprecedented extent of the outbreak, declared it a threat to international peace and security. As at October 22, 10 114 cases and 4 912 deaths (49 per cent) had been recorded in the three affected countries, Liberia, Guinea and Sierra Leone.

There are now grave concerns that the Ebola epidemic could destroy what is left of the civic structures in the three main affected countries. To date 450 healthcare workers have been infected and 244 have died, dramatically depleting the meagre health resources of these poverty stricken countries and further aggravating other formidable health challenges such as malaria and diarrhoeal disease.

Their fragile economies have also been hard-hit by the necessary control measures such as the curtailment of movement affecting, among others, the food supply. Ebola is truly developing into a humanitarian tragedy on a monumental scale. How did this come about and what are the risks of this dreadful epidemic spreading beyond these countries?

Ebola is a new disease, with the first outbreak recognised in 1976 in Sudan and Zaire (now the Democratic Republic of the Congo. The virus was named after the Ebola River in the DRC.

Since then there have been some 25 outbreaks in eastern and central Africa, each involving a few hundred cases, with death rates varying from 25 to 90 per cent. These outbreaks have generally lasted from a few weeks to a few months and have then died out

The virus is spread by direct contact with infectious body fluids from a patient who has developed symptoms of the disease. There is no evidence of it being spread by any other means, including through the air.

Therefore, by identifying a patient and isolating him/her for 21 days (the upper limit of the incubation period of the infection), as well as identifying contacts and similarly quarantining them for 21 days, the epidemic should be stopped in its tracks. Indeed this has been the case in the US and Spain, as well as in Senegal and Nigeria, following isolated imported cases.

Paradoxically the infection should be relatively easy to control, but why then has it spiralled out of control in West Africa where it has now lasted close on a year and is still on an upward trajectory?

A number of socio-economic, political and cultural factors are involved. These three countries rank among the poorest in the world – the multi-dimensional poverty index of the UNDP (United Nations Development Programme) puts Guinea having the highest rate of severe poverty in the world, 68,6 per cent, with Liberia and Sierra Leone not too far behind at 52,8 per cent and 46,4 per cent respectively.

Liberia and Sierra Leone have also just emerged from ruinous civil wars, further aggravating the resistance, distrust and anger of the communities and several healthcare workers have even been murdered. Ingrained cultural practices, especially relating to the preparation of the dead for burial, have promoted the spread of the virus in at least 50 per cent of cases. Health services are pitiful. For example, Liberia has 0,1 doctors, 1,7 nurses and eight hospital beds for every 10 000 people.

Could infection spread beyond the three affected countries? Fifteen countries with land borders have been on high alert for potential importation. But what of more remote spread by air travel, as has occurred in the US, Spain and Nigeria?

Fortunately control is facilitated by the virus only becoming transmissible once symptoms of the disease develop. The risk from a planned medical evacuation under strict bio-containment is extremely remote. However, unplanned entry of infected patients may pose a somewhat higher risk to healthcare workers and other contacts, particularly if Ebola is not suspected.

Ebola is thus not an imminent threat to countries outside of those already affected, other than the isolated imported sporadic cases, but there is no cause for concern that these could develop into significant outbreaks. However, the history of global health will, in the future, record this Ebola outbreak to be one of the humanitarian disasters of this century.

• Barry David Schoub MB BCh, MMed , MD, DSc, FRC Path, FCPath,  FRSSAf, MASSAf was appointed the first professor of virology at Wits in 1978; director of the National Institute for Virology, 1982 and founding executive director of the National Institute for Communicable Diseases,2012, retiring in August 2010.
• He served on several international advisory committees of WHO including polio, measles, RSV, influenza, the Advisory Committee for Poliomyelitis Eradication [ACPE] and the International Health Regulations [IHR], as well as the Board of the International Association of Public Health Institutes (IANPHI).
• He was founding chairman of SA’s National Advisory Group on Immunization. He has published over 280 scientific publications.
• Among his awards are: the Order of Mapungubwe from the State President; the Paul Harris Award of Rotary International; the 2012 Jewish Achievers Award; the first Lifetime Achievement Award of the African Society for Laboratory Medicine.