Epidemics That Didn't Happen

Case Study:

Ebola
in West Africa

How improved systems and skills following deadly epidemics contained two Ebola outbreaks  
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Resolve To Save Lives
Microscopic image of the Ebola virus
Virus Image: Microscopic image of the Ebola virus. Courtesy: Frederick A. Murphy

About Ebola

Rare but deadly, Ebola Virus Disease is caused by a virus thought to have originated in bats. In recent years, humans have also become reservoirs of the virus,1 spreading it through bodily fluids.2 Although there have been relatively few Ebola outbreaks since the virus was discovered in 1976, they have been devastating, with death rates ranging from 20% to 90%.

Initial symptoms are often flu-like, but can progress to liver and kidney dysfunction and internal and external bleeding.3 Treatments, such as oral or intravenous fluids and monoclonal antibodies, can greatly improve chances of survival.4 Effective vaccines against the Zaire strain of the virus have been available since 2019, but supply remains limited.5 Nonetheless, the World Health Organization (WHO) has been able to coordinate swift vaccine delivery during recent outbreaks.

In 2014-2016 and 2018-2020, gaps in detection and response led to delays that allowed two Ebola outbreaks to become epidemics. The first, in West Africa, began in Guinea and spread to Liberia and Sierra Leone, as well as seven other countries including the United States and Italy, between 2014 and 2016. Subsequent analysis pointed to failures that hampered response efforts.6

In the past decade, two Ebola epidemics claimed nearly 14,000 lives.

In 2014, Guinea lacked a formal emergency response system, a public health agency and trained field epidemiologists.7  Communication about how to limit risk of Ebola spread was poorly handled, leading to resistance, mistrust and the viral spread of misinformation; one rumor held that the virus wasn’t even real.8 That entire parts of the country were simultaneously cordoned off to prevent the spread of disease only added to a culture of fear.9 Border controls to limit spread to neighboring countries were not established until five months after the outbreak had been declared.10 Vaccines were not available at the outset of the outbreak; as the epidemic progressed, only those enrolled in clinical trials could access them. Vaccination rollout was further hampered by misinformation, including that the vaccine made women infertile or men impotent.11

By the time the West Africa Ebola epidemic ended in 2016, approximately 28,600 people had been infected, and 11,325 people had died. The cost to the global economy was estimated to be $53 billion.12

Despite success containing several earlier Ebola outbreaks, the Democratic Republic of the Congo (DRC) was hampered from the start in its response in 2018, resulting in an epidemic that lasted until 2020. Due to ongoing regional conflict, the disease surveillance system had broken down. Health care workers were on strike because of a salary payment dispute in May of 2018—the time when investigations later determined the first case of Ebola had emerged.13 As a result, no suspected cases were identified, and no alerts were issued for two months. The outbreak became so large that, at its peak, 16,000 local responders were required, in addition to 1,500 staff sent by WHO and more deployed by other international partners.14 A total of 171 health care workers were infected,15 and in total the epidemic caused about 2,280 deaths among 3,470 diagnosed cases.

In 2021, Ebola outbreaks of the Zaire strain emerged again in both Guinea and DRC under strained circumstances, with each country dealing with multiple infectious disease outbreaks simultaneously—including COVID-19. But the outcomes were drastically different. Guinea’s outbreak was declared over after six months and 12 deaths. And the outbreak in DRC ended after three months and 11 deaths. Vaccines were administered successfully, health care worker infections were limited and neither outbreak spread beyond the region in which it emerged.

What changed?

Guinean Red Cross workers carrying the corpse of a victim of Ebola during the 2014-2016 epidemic
Guinean Red Cross workers carrying the corpse of a victim of Ebola during the 2014-2016 epidemic. Courtesy: KENZO TRIBOUILLARD/AFP via Getty Images

WHAT HAPPENED

On January 18, 2021, a nurse from the N’zérékoré Region of Guinea arrived at a clinic in Gouécké with a headache, vomiting and fever, among other symptoms. She was diagnosed with typhoid and released. Days later, her condition had become so severe that she was admitted to a hospital, where she was diagnosed with malaria and salmonella. Following discharge, however, her condition only worsened. She sought care at a private clinic and subsequently from a traditional healer, to no avail. She died several days later.16

In the week following her February 1 funeral, the woman’s husband and other family members became ill.17 Some family members’ symptoms were recognized as consistent with viral hemorrhagic fever and reported to the national epidemic alert system on February 11. Blood specimens were taken from two hospitalized patients on February 12, and the nearby regional lab confirmed the infections to be Ebola the next day.18 Meanwhile, the woman’s husband had traveled across the country to the capital city of Conakry for treatment, creating potential new exposures. He too was confirmed to have Ebola, and on February 14, the government announced the outbreak.

Amid simultaneous outbreaks of yellow fever, measles, polio and COVID-19, the new Ebola outbreak—undetected for nearly a month—threatened to hit the same region of the country where the massive 2014-2016 Ebola epidemic emerged.

THE RESPONSE IN GUINEA

Within 24 hours of the first alert confirming Ebola’s reemergence, Guinea activated national and district emergency operations centers (EOCs) to coordinate containment.19 Since the 2014-2016 Ebola epidemic, Guinea had established the National Agency for Health Security (ANSS) to aid in detecting and stopping outbreaks, and with the support of the U.S. Centers for Disease Control and Prevention and other partners, had established a national EOC as well as 38 EOCs at the district level.20 Furthermore, the country had invested in hiring and training a range of public health officials—from epidemiologist disease detectives to risk communication and community engagement specialists, who could help build trust and combat misinformation—to quickly respond to the outbreak. ANSS provided a centralized coordination hub from which officials could activate an effective response. The day after the lab tests confirmed Ebola, ANSS deployed teams of staff and partners from key stakeholder organizations to begin thorough case investigation and contact tracing.21,22 The Africa Centres for Disease Control and Prevention (Africa CDC), which was established in 2017 by the African Union, partly in response to the 2014-2016 Ebola outbreak, began holding coordination meetings the day following the outbreak declaration and deployed a support team to Guinea two days later, on February 17.23 Teams of public health workers, all coordinated by ANSS, sprang into action to monitor the outbreak’s spread. More than 10,000 additional alerts of potential cases were triggered, 96% of which were investigated. More than 1,100 contacts were identified from 23 initial cases, and nearly all of them were monitored daily. Because the outbreak’s epicenter was located near the borders of Liberia and Côte d’Ivoire, officials held coordination meetings among the three countries and conducted over 2.5 million screenings at their points of entry.24 In local areas where Ebola was known to be present, officials established screening checkpoints.25
A health worker preparing a dose of Ebola vaccine
A health worker preparing a dose of Ebola vaccine. Courtesy: ISSOUF SANOGO/AFP via Getty Images
Health workers standing around a shipment of Ebola vaccine in Guéckédou, Guinea in February 2021
Health workers standing around a shipment of Ebola vaccine in Guéckédou, Guinea in February 2021. Courtesy: CAROL VALADE/AFP via Getty Images

At the start of the outbreak, PCR lab capacity was expanded in N’Zérékoré, the capital of the affected region, to test for Ebola quickly and accurately—eliminating the need to send samples further afield.26 Simultaneously, genetic sequencing capabilities were enhanced in the nation’s capital of Conakry to better understand the dynamics of new cases and how they compared with past outbreaks. 27 During the 2014 epidemic, samples initially needed to be sent to France for testing—causing significant delays in disease identification. During the 2021 outbreak, laboratory confirmation took only two days, thanks to expanded laboratory capacity.

At the community level, ANSS and partners deployed 900 trained mobilizers to help prevent the spread of Ebola and support families in using safe and dignified burial practices. Two vacant infectious disease treatment centers in the region were rehabilitated to manage Ebola patients. Local health facilities were evaluated on their infection prevention and control (IPC) practices, while receiving additional training and supplies. Throughout the outbreak, nearly 11,000 people were vaccinated against Ebola, including 2,800 health care workers and others at high risk due to links to Ebola cases. 28

By the time the outbreak was declared over in June 2021, 23 cases had been identified; 12 people had died, including five health care workers.29 Although it took nearly a month for officials to detect the outbreak,30 this was a dramatic improvement from 2014, when detection took four months.31 Extensive upgrades to Guinea’s preparedness infrastructure facilitated a shorter time to detection, which was followed by a prompt and effective response that contained the outbreak, saving lives and preventing the kind of suffering and devastation experienced just a few years earlier.

Guinea has made impressive strides to strengthen its national health security since the tragic 2014-2016 Ebola epidemic. The determination of the country’s epidemic and response leadership, with support from international partners, has dramatically changed how disease outbreaks are handled in the country

Amanda McClelland, Senior Vice President of Prevent Epidemics, Resolve to Save Lives
Health workers from the Guinean Ministry of Health registering medical staff for the Ebola vaccine in February 2021 at the N’Zérékoré Hospital. Courtesy: CAROL VALADE/AFP via Getty Images

Guinea has made impressive strides to strengthen its national health security since the tragic 2014-2016 Ebola epidemic. The determination of the country’s epidemic and response leadership, with support from international partners, has dramatically changed how disease outbreaks are handled in the country

Amanda McClelland, Senior Vice President of Prevent Epidemics, Resolve to Save Lives

KEY PREPAREDNESS FACTORS

  • Risk Assessment & Planning
  • Emergency Response Operations
  • National Laboratory System
  • Disease Surveillance
  • National Legislation Policy & Financing
  • Human Resources
  • Risk Communications

2014–16 EPIDEMIC (889 DAYS)

  1. Start32

  2. Detection33

  3. Verification34

  4. Control35

  5. Bottleneck Multiple, including lack of coordinated response mechanism and trained health workforce

2014–16 EPIDEMIC (889 DAYS)

  1. Start

  2. Detection

  3. Verification

  4. Control36

  5. Bottleneck Low awareness or clinical suspicion by health workers

    FacilitatorMultisectoral response team mechanisms in place

By the Numbers – Guinea
2014-2016 epidemic 2021 outbreak
Duration 889 days 153 days
Cases 28,616 cases 23 cases
Deaths 11,310 deaths 12 deaths
Cost of containing the outbreak >$3.6 billion43 < $100 million44
Case fatality ratio 70% 52%
Improvements in health security that helped prevent an epidemic
2014-2016 epidemic 2021 outbreak
Coordination 0 Emergency Operation Centers 1 national and 38 district-level EOCs
Staff Few trained field epidemiologists 179 trained field epidemiologists
Lab capacity 0 Ebola testing labs (sent to Lyon, France and Hamburg, Germany for initial testing);37 results in about 7 days38 National and regional testing; results in about 1 day39
Identification (from first known illness to laboratory identification) 4 months after first case40 1 month after first case
Containment Border controls weren’t activated for five months. More than 2.5 million screenings were conducted at points of entry.
Vaccination Experimental vaccine in clinical trials 11,000 people vaccinated
Percentage of cases added to contact list following positive test 28-31%41 39%42
A street scene in Goma, North Kivu province, DRC.
A street scene in Goma, North Kivu province, DRC. Courtesy: Shutterstock

WHAT HAPPENED IN THE DEMOCRATIC REPUBLIC OF CONGO (DRC)

On September 5, 2021, a girl in North Kivu province, DRC, was admitted to a local health center with fever, headache and physical weakness. She was discharged two days later but readmitted the following week with additional symptoms, including diarrhea and vomiting. She tested positive for malaria, a common infection, and died shortly after. In the following weeks, both her father and sister fell ill and died (her sister had also tested positive for malaria). Local public health authorities were informed of the deaths on September 30, and a team was sent to investigate, but no samples were taken to test for Ebola, which had not been considered a potential diagnosis at the time.

In early October, a three-year-old neighbor of the family fell ill with similar symptoms, as well as abdominal pain, difficulty breathing and vomiting blood. He died on October 6. Samples of his blood were taken the following day and he was confirmed to have had Ebola.45 Public health authorities suspected that the outbreak had likely been spreading for some time and recognized that if it was not controlled quickly, it would expand rapidly. The disease confirmation had been complicated by co-infections of malaria and other diseases with similar symptoms, delaying the diagnosis. Ongoing violent conflict in the region made the stakes even higher.

THE RESPONSE IN DRC

Working with WHO and other partners, local health officials quickly took action. During and after the 2018-2020 outbreak, DRC began building its surveillance systems, training contact tracers and developing greater lab capacity—all of which improved the country’s ability to mount an effective response. The day after the new Ebola case was confirmed in October 2021, 150 contacts of the deceased had already been identified. During the course of the outbreak, authorities tracked possible cases at health facilities and elsewhere through nearly 22,000 alerts issued from across the health system, of which 98% were investigated. More than 4.7 million people were screened at points of control established to keep Ebola cases from spreading throughout DRC or beyond its borders.

Approximately 1,800 samples from suspected cases and contacts were tested for Ebola in four regional labs46 opened in response to the 2018-2020 outbreak.47 Due to expanded local testing capacity, time to test the initial samples was reduced from five days48 in 2018 to two days in 2020.49

Across the affected region, health care workers were trained and retrained in IPC measures—which keep patients and health care workers safe from avoidable infections. Training included how to screen for potential Ebola cases, and health care workers also received IPC kits with proper personal protective equipment. During the 2021 outbreak, not a single health care worker was infected.

A medical worker puts on her Personal Protective Equipment (PPE) ahead of entering an Ebola Treatment Centre
A medical worker puts on her Personal Protective Equipment (PPE) ahead of entering an Ebola Treatment Centre run by The Alliance for International Medical Action (ALIMA) on August 12, 2018, in Beni. (Photo by John WESSELS / AFP) (Photo by JOHN WESSELS/AFP via Getty Images)
 

The 2021 outbreak of Ebola in DRC was declared over three and half months after it was declared, with only 11 cases and nine deaths. The previous outbreak had taken over two years to bring under control.

For the first time in DRC, authorities had a fully licensed vaccine from the start of the outbreak. The Ebola vaccine was trialed and administered on an experimental basis during the 2014-2016 epidemic and was shown to be both safe (causing only mild side effects) and 97.5% effective.50 It was subsequently approved by Congolese regulatory authorities in February 2020 and made available for use during the 2021 outbreak.51 In DRC, nearly 2,000 people were vaccinated during the outbreak, including case contacts and frontline health care workers. Community groups led risk communication activities and promptly addressed misinformation rumors about the vaccine through targeted campaigns.

To support decision-making grounded in evidence, emergency response leaders worked on a collaborative research system to easily share information with each other about the outbreak. Participating partners conducted surveys throughout the outbreak to further inform the response. Although it took DRC’s public health system a month to identify the 2021 outbreak,52 this was half the time it took in 2018.

The 2021 outbreak of Ebola in DRC was declared over on December 16, three and half months after it was declared, with only 11 cases and nine deaths.53 The previous outbreak had taken over two years to bring under control.54 Lessons learned from the 2018-2020 outbreak laid the groundwork for the far more successful 2021 response. Surveillance and laboratory systems, IPC procedures and training, vaccine rollout and contact tracing were all dramatically expanded and improved.

KEY PREPAREDNESS FACTORS

  • Risk Assessment & Planning
  • Emergency Response Operations
  • National Laboratory System
  • Disease Surveillance
  • National Legislation Policy & Financing
  • Human Resources
  • Risk Communications

2018 epidemic (702 days)

  1. Start55

  2. Detection56

  3. Verification57

  4. Control58

  5. Bottleneck Multiple, including breakdown in disease surveillance and regional conflict

2021 OUTBREAK (103 DAYS)

  1. Start

  2. Detection

  3. Verification

  4. Control

  5. Bottleneck Low awareness or clinical suspicion by health workers

    Facilitator Health workforce trained in surveillance and response

By the Numbers – DRC
2018-2020 epidemic 2021 outbreak
Duration 701 days 103 days
Cases ~3,470 cases59 11 cases60
Deaths ~2,280 deaths61 9 deaths62

This ongoing improvement in response was no accident. DRC made critical changes to its infrastructure, planning and human resources to prevent a deadly and economically damaging epidemic

Billy Yumaine, Deputy Director of the National Reproductive Health Program, DRC Ministry of Health
A medical worker disinfecting a local Ebola Treatment Centre in North Kivu in 2021. Courtesy: Alain Uaykani/Xinhua via Getty Images

This ongoing improvement in response was no accident. DRC made critical changes to its infrastructure, planning and human resources to prevent a deadly and economically damaging epidemic

Billy Yumaine, Deputy Director of the National Reproductive Health Program, DRC Ministry of Health

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References

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  21. Key organizations included the African Field Epidemiology Network, German Cooperation, Médecins Sans Frontières, WHO Guinea Office and the International Organization for Migration.
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