Global Response to the 2013 Ebola Outbreak

The aim of this essay is to present the global response to the epidemic of Ebola virus disease that spread in West Africa from the end of the year 2013. Ebola virus (EBOV, formerly designated Zaire ebolavirus) is one of five known viruses within the genus Ebolavirus and the Ebola Virus Disease is a viral haemorrhagic fever, a rare and deadly disease most commonly affecting people and nonhuman primates. (1) The epidemic started in 2013 was the largest ever seen interesting the Ebola virus.

is it possible to identify some trace of the beginning of the spread back in December, noticing how fast it developed in one of the biggest Index cases was traced back in December and rapidly developed in one of the biggest epidemics ever seen, starting from Guinea and spreading in Congo, Sierra Leone and Liberia. The number of deaths related with the disease where impressive, as reported by the World Health Organisation in data 6 of January 2016, from 2014 to 2016 have been confirmed 28,616 cases and 11,3001 deaths in these counties. The diseases have continued to spread, the last case recorded was the first August 2018 in the North Kivu province in the democratic republic of Congo.

However, despite all the tragic death related to the virus, the global response action helped to prevent a further spread of the disease and an actual restraint of it, preventing another major spread. This outbreak prompted an efficient and rapid international response: 7 US agencies and 11 international agencies where counted to respond to the disaster. However there are many different opinions regarding how the outbreak of the Ebola virus disease was managed and controlled, one example is related with the article written by professor Alexander Kekule in 2015 (0) where it is specified that the WHO is incapable to provide an adequate medical assistance in less developed region of the world, together with the lack of infrastructure and medical health centre. This essay will examine how the global response was managed during the first outbreak and what, according to recent studies and evidence, could have been done differently. In conclusion, it is obvious that the Ebola virus's disease, unfortunately, hasn't been completely eradicated, as a new outbreak has commenced in the Democratic Republic of Congo starting from the year 2018, but hopefully the global response, with the main international authorities.

The Ebola virus disease (EVD) is caused by infection with the Ebola virus, from the family Filovirus. It causes a severe haemorrhagic fever (2). There are five strains that have been identified: Zaire, Sudan, Bundibugyo, Ta?± Forest and Reston. The first three cause most disease in humans with case fatality rates ranging from 25% to 90%.

Ebola viruses have significant epidemic potential, as shown by the 20132016 West African outbreak. (3) Ebola is believed to be zoonotic, and despite large investigations, the natural reservoir is unknown. Non-human primates have been a source of human infection; however, they are not thought to be the reservoir as they develop severe, fatal illness when infected. Most of the evidence now suggests that bats are the reservoir host for the virus, they are most likely to be the source, it is believed that the virus is natural born and starting from the bats, once they get infected, they can easily transmit the virus to other mammals, including humans. Once the first human has been contaminated there will be a spread of the disease between humans through body fluids or blood or by touching and taking care of the people who have died because of the disease. Body fluids, blood, secretions are the primary source of contamination.

(4) The Ebola virus has a specific structure, it carries a negative sense RNA genome in virions that are cylindrical and contain viral envelope, matrix and nucleocapsid component. The overall cylinders have a virally encoded glycoprotein (GP) projecting as 7-10 nm long spikes from its lipid bilayer surface. (5) It has been discovered that the glycoprotein allows the virus to introduce its contents into monocytes and/or macrophages, where cell damage or exposure to viral particles may cause the release of cytokines associated with inflammation and fever. Furthermore, the glycoprotein allows the entrance of the virus into endothelial cells, which damages vascular integrity. GP may contribute to the haemorrhagic fever symptoms. In human and mammal bodies there is two way of entry for the Ebola virus, the first one is a cholesterol transporter protein which seems to be essential for the entrance of the Ebola virions and their replication; the second way to enter is through a protein-coding gene known as HAVCR1. The Ebola virus is an acellular virus, it can't replicate through any type of cellular division, it used to a combination of host and virally encoded enzyme to produce multiple copies of himself.

(5) Once entered the Ebola virus starts to replicate very efficiently, in a very unusually high rate that overwhelms the protein synthesis apparatus of infected cells and host immune defences. In the humans or mammal's organism, once a risk of infection has been detected there is an immediate response to the attack. The immune and inflammatory system fight immediately together, with the help of other cell types as monocytes and macrophages. The different studies that have been conducted on the Ebola virus also have shown that endothelial cells, mononuclear phagocytes, and hepatocytes are the main targets of infection. It has been proved that the GP, encoded glycoprotein plays a key role in the manifestation of the Ebola virus. The components of the immune system that may protect against Ebola virus infection have not been defined. Antibody against Ebola virus GPs is readily detectable in patients who recover from Ebola virus infection.

Once a host has been contaminated by the Ebola virus, it takes around 14-21 days to start developing the symptoms. Humans are not contagious until they develop symptoms. These start with flu-like symptoms, associated with malaise, headache, typically like a migraine and fever. Ince the disease progress that patients start to develop abdominal pain, severe diarrhoea and vomiting. With the progression of the disease the next symptoms will include bleeding and coagulation abnormalities, together with a lot of haematological irregularities, also a maculopapular rash associated with varying severity of erythema and desquamate. (5.1) (5.2)

Once identified the disease, the World health organization can declare that status of the outbreak. (8) According to the WHO website, an outbreak is defined as ""The occurrence of disease cases in excess of normal expectancy. The number of cases varies according to the disease-causing agent, and the size and type of previous and existing exposure to the agent. Means that there are more cases of the disease are in excess of what would normally expect to be in a specific community. There is a timeline of events that progressively highlight the velocity of the spread of the Ebola disease.

Many risk factors have been identified during the Ebola outbreak, these risks, in fact, have contributed significantly to the spread of the disease and to the inability and impossibility to contain the outbreak. Social, biological and logistic drivers of transmission, all combined have facilitated the beginning of the outbreak in 2014. (9) Some of those risks are attributable to the particular geopolitical area where the disease has begun. These are for example population structure and the geography, the lack of infrastructure, the economic factor and the cultural, religious and behavioural factors, like the burial ritual. Following all these risks factors there have been unexpected, unprecedented devastating consequence. Globally the outbreak exceeded the ability of any one government or association to contain the spread, and furthermore, has been highlighted that the WHO response might have not been immediate and efficient as it should have been.

However, once the status epidemic has been declared, a global response to the emergency has been activated. The WHO worked in partnership with many other organisations to contain the outbreak and to mitigate the risk or outbreak outside of the area already affected. This group of organisations include international and national/local administration. This helps came from a different source, providing different support, like building treatment centre, donating founding, recruiting volunteers all over the world. (10) WHO also works in partnership with the organisation like UNICEF, Global Outbreak Alert and Response Network, United Nation and in particular UN Mission for Ebola Emergency Response (UNMEER), and UNICEF, WFP, OCHA, UNFPA. WHO has also collaborated and coordinate other international agencies as Centre for Disease Control (CDC), M?©decins Sans Fronti?res (MSF), the International Federation of the Red Cross (IFRC), the International Organization for Migration (IOM), UNAIDS and partners of the Global Outbreak Alert and Response Network (GOARN). It is globally recognized that the strict collaboration between these organisations is vital to the ending and control of the outbreak.

A plan of action has been designed to manage the outbreak and to control the damage. Many documents and plans of action have been produced since the outbreak in 2014 to try to mitigate the spread of the disease and to manage as best as possible this new unpredicted global health emergency. (11) The WHO has elaborated in 2014 a 107 pages documents titled ""Ebola strategy - Ebola and Marburg virus disease epidemics: preparedness, alert, control and evaluation in which, step by step has been identified the different phases of an outbreak management, starting from prevention, education, assessment, planning, intervention and evaluations. Many other written report and documents have been produced, another one which contributed understanding and managing the disease is a document called "" 2015 WHO strategic response plan - West Africa Ebola Outbreak ""in which is possible to understand all the principles that guide WHO in the purpose of containing the outbreak, stop the transmission in the already affected communities, prevent the spread in other border one another countries, reactivate health centre and promote resilience and finally coordinate Ebola national and international response. Preparedness, alert, control and evaluation, have been the keys in the management of the outbreak.

However, many studies were produced previously to set up the strategy to adapt to prevent the risk of an outbreak and to implement a community-based surveillance system. One of the keys of an efficient outbreak management and containment is to maintain always a high standard level of communication and sharing of information between all the organisations involved. Fundamental is a reliable information management and transparency of communication. 3 are the phases identifiable in the Ebola response in Africa, these phases had the outcome of outline a rapid sequence for a response, focus on increasing capacities and respond to the consequences of the risks.

The phase 1 took place from August to December 2014 and involved WHO and partner in implementing many more health centres in the areas affected by the disease, rapidly involvement for a training team to ensure education for a safe burial ceremony and body disposal and basic hygiene notions, and finally to increase the social capabilities.

The phase 2 took place from January 2015 to July 2015 and involved an increase of capacity for contact tracing and case finding together with the increase of the community engagement. During this phase must always be considered that the organisational management and response was joined by a large group of scientist and organisation working on a vaccine, treatment and cure. The first vaccine trial for Ebola disease started in Guinea during phase 2. The research and development of a vaccine included several tests on the antigen test and the nucleic acid test together with a therapeutic trial of medicine. The phase 3 of the response took place from August 2016 to mid-year 2016 and included the importance of maintaining a safe triage system and early recognize of the disease, the importance of building a rapid response team, providing incentives to individual as communities to maintain high standard of basic hygiene precaution, to improving the outcome and treatment for patients and Ebola surviving, to reduce to zero the Ebola virus cases.

(17) Finally, the outbreak of Ebola disease has been declared concluded in data 7 November 2015 in Sierra Leone, in data 1 June 2016 in Liberia and in data 6 June 2016 in Guinea. According to with the WHO the definition of Zero Ebola case is the following ""EVD will be considered ended in any one of the above countries after 42 days have passed since the last confirmed case has tested negative twice for the virus on blood samples. After the 42-day period has elapsed, each country should maintain a system of heightened surveillance for a further 90 days and ensure ongoing EVD surveillance and notification thereafter. However, a blood sample test and further studying should always continue to guarantee the continuation of the surveillance of EVD disease and a health-safe practice should always be sustained.

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