This Ebola Outbreak Might Not Go Away For A Very Long Time

The Ebola outbreak in West Africa continues to spread like wildfire, and it shows no signs of slowing down.

As of this morning, there were 21,373 cases of Ebola in Guinea, Liberia and Sierra Leone, according to the World Health Organization. Since the outbreak began in late 2013, there have been a total of 8,468 deaths.

The Ebola virus disease was first discovered in the Democratic Republic of the Congo in 1976, and by 2013 had caused about 20 recorded outbreaks across East and Central Africa. The outbreaks had been restricted to rural areas and confined to small clusters of villages. In each case, containment was achieved within a few months.

According to a panel of more than 60 World Health Organization experts, however, “the current epidemiologic outlook is bleak.”

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Said experts published a study in the New England Journal of Medicine back in September 2014, where they stated, “We must therefore face the possibility that Ebola virus disease will become endemic among the human population of West Africa, a prospect that has never previously been contemplated.”

The word we have to take note of that the authors chose to use is endemic.

Endemic is a term used to describe any malady that routinely crops up without having to be reintroduced from an outside source – either imported from another country or another species.

Does this sound familiar?

The flu is a perfect example of an endemic disease. In the United States, various strains of the flu continue to reappear year after year without any trouble.

In the past 40 years, the multiple Ebola outbreaks were never referred to as “endemic” simply because the original source of each infection was believed to be attributed to an animal that somehow infected a human.

Changing the technical description of the current Ebola outbreak from epidemic to endemic is more than a matter of semantics. It’s the difference between a sprint and a marathon.

A sprint requires a massive surge of effort after which the runner can recover. A marathon, however, requires an entirely different approach and extensive resources to go the distance, much like endemic Ebola.

So, what’s different this time?

All of the prior outbreaks of Ebola were located in such remote areas that the combination of fast action and the relative isolation of the communities allowed for the outbreak to remain contained. But following that same strategy in the current case was close to impossible for three reasons: Guinea, Liberia and Sierra Leone.

These three countries are not only much more densely populated than the rural villages where Ebola once appeared, but they also intersect in such a way that a disease like Ebola is able to quickly escalate and spread.

Additionally, language barriers can be attributed to the spread of the disease as radio messages were initially in official languages only, not correlating with the various different community identities – spread was inevitable.

Mainstream health care in West Africa is severely limited and sick relatives are typically nursed at home by family members. Further care is often sought from traditional healers, unofficial providers and private pharmacies rather than government health facilities.

Peripheral health units are only equipped to diagnose and treat malaria, pregnancy and a few other key conditions, and if patients do go to a hospital, in many settings there is a lack of basic equipment such as gloves, aprons, running water and soap. The number of trained health care professionals of all cadres is very low.

There is also a major stigma associated with Ebola, similar to the early years of HIV care. The present Ebola outbreak began very close to where civil war erupted in Sierra Leone in 1991, and trust in the government in this region is very low.

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Although acceptance of Ebola has rapidly increased, there was initially disbelief about its existence, and conspiracy theories about population control were prominent and sometimes roused by the media.

There is a general agreement that a sufficient early international response, when traditional control strategies of case isolation, contact tracing and geographical containment were feasible, were not forthcoming.

The World Health Organization was slow to deploy experts, not appreciating the potential seriousness from the outset, and approaches used in smaller outbreaks were followed rather than adapting to new models of care. There was an initial scarcity of organizations willing to deploy clinical staff and many traditional health non-governmental organizations withdrew their in-country staff.

All of these factors can be attributed to the now endemic state of the Ebola virus disease.

But where did Ebola come from in the first place?

Most virologists believe that the outbreaks are a result of a spillover from one or more animals that naturally carry the virus.

One leading theory is that humans have contracted Ebola by consuming infected fruit bats – mainly due to the Marburg disease (a closely related malady to Ebola) being linked to bats.

The very characteristics of Ebola that make it so lethal also simultaneously block it from becoming a strong candidate to be endemic. Since Ebola kills pretty readily, for example, it doesn’t have the opportunity like HIV to pass itself on. And there’s no chronic carrier of this virus who appears to harbor the virus even after it has been eliminated from a community.

Then can we find a way to put an end to Ebola?

Ebola appears to be a virus that is slow to mutate, and the pathogen steadily wanes as the number of people who have developed immunity increases. With proper controls, experts say the virus would find it increasingly difficult to spread among the population until it eventually disappeared from humans and survived only in its so-called animal reservoir: the fruit bat.

In this case however, epidemiologists fear that the virus could continue to linger in small pockets, extending its life in humans and potentially mutating in a way that makes fighting more difficult.

Dr. Jeremy Farrar, director of the Wellcome Trust, and Dr. Peter Piot, director of the London School of Hygiene and Tropical Medicine, published an editorial that stated that the current Ebola situation has helped to degrade an already meager system of health care, and that such “disintegration” would have broad consequences and only worsen with time.

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“West Africa will see much more suffering and many more deaths during childbirth and from malaraia, tuberculosis, HIV/AIDS, enteric and respiratory illnesses, diabetes, cancer, cardiovascular disease, and mental health during and after the Ebola epidemic,” the duo wrote.

According to Christopher Dye, who serves as director of strategy in the office of the director general at the World Health Organization, if Ebola is still persisting a year from now, “The whole response will need to be integrated back into the health system,” he told Scientific American.

Although changes to the Ebola response are under active discussion, such as creating isolation units at hospitals, Dye told the news source that the focus right now still needs to be on emergency response.

“I think the reason we have used the word endemic in the first instance is to emphasize that the persistence of transmission has been a lot longer than anything we’ve seen before,” Dye told Scientific American. But it could also be used to point to the need for an entirely different kind of response, one that would hinge on addressing the virus beyond an exponential growth phase, “where we get the virus to low levels in the population and there will be a different kind of response.” 

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