The end of the Ebola virus disease epidemic: has the work just begun?
Authors: Mark J Siedner, John D Kraemer
Journal: The Lancet Global Health (2017)

The response to the west African Ebola virus disease epidemic in 2016 illustrated the stark dichotomy of both the failings and the remarkable potential of global public health architecture. A stuttering, uncoordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands,1Siedner MJ Kraemer JD The global response to the Ebola fever epidemic: what took so long?.http://blogs.plos.org/speakingofmedicine/2014/08/22/global-response-ebola-fever-epidemic-took-long/Google Scholar was followed by one of the most successful global partnerships between foreign and local governments and multinational aid organisations to stem an international health crisis. After the region was declared free from an active epidemic in January, 2016, any accolades were intermixed with warnings that the greatest work was left to be done: rebuilding an infrastructure and workforce capable of preventing future epidemics from enacting similar devastation and enabling provision of quality health care in the region.2Bell BP Damon IK Jernigan DB et al.Overview, control strategies, and lessons learned in the CDC response to the 2014–2016 Ebola epidemic.MMWR Suppl. 2016; 65: 4-11Crossref PubMed Scopus (116) Google Scholar Fortunately, a panoply of global health-care bodies, including the UN, World Bank, and the African Development Bank have expressed their commitments to this goal,3UNWorld BankEuropean UnionAfrican Development BankRecovering from the Ebola crisis: a summary report.http://www.undp.org/content/dam/undp/library/crisisprevention/UNDP_CPR_EbolaRecovery_2015.pdfDate: 2015Google Scholar but whether it will be met remains an open question. In the wake of these commitments comes a reminder of the enormity of the task at hand. In The Lancet Global Health, Alexandre Delamou and colleagues4Delamou A El Ayadi AM Sidibe S et al.Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study.Lancet Glob Health. 2017; (published online Feb 22.)http://dx.doi.org/10.1016/S2214-109X(17)30078-5Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar present data on the lasting effect of the Ebola virus disease epidemic on maternal and child health-care services in the rural Forest region of Guinea—the location of approximately two of every three reported deaths from Ebola virus disease in the country. They analysed aggregated monthly service use data from health systems in six districts, using an interrupted time series analysis to estimate trends in antenatal care, facility-based (institutional) delivery, and receipt of five childhood vaccinations (polio, pentavalent, yellow fever, measles, and tuberculosis) across three periods: pre-epidemic (January, 2013, to February, 2014), epidemic (March, 2014, to February, 2015), and post-epidemic (March, 2015, to February, 2016). Delamou and colleagues showed that trends in both maternal and child health indicators significantly dropped during the epidemic—a tragic but unsurprising finding, and one in agreement with similar reports from Liberia and Sierra Leone.5Ly J Sathananthan V Griffiths T et al.Facility-based delivery during the Ebola virus disease epidemic in rural Liberia: analysis from a cross-sectional, population-based household survey.PLoS Med. 2016; 13: e1002096Crossref PubMed Scopus (31) Google Scholar, 6Bolkan HA Bash-Taqi DA Samai M Gerdin M von Schreeb J Ebola and indirect effects on health service function in Sierra Leone.PLoS Curr. 2014; 6 (pii: ecurrents.outbreaks.0307d588df619f9c9447f8ead5b72b2d.)PubMed Google Scholar But less well described, and perhaps more concerning, is their finding of durable, detrimental effects on basic health-care delivery up to a year after the epidemic ended in Guinea. Indeed, they estimate persistently stagnant or negative trends in all health indicators assessed through the end of their observation period in March, 2016. These estimates correspond to thousands of missed opportunities for prenatal care, safe deliveries, and preventable early life infections—the cornerstones of maternal and child health. We commend the investigators for this analysis, but note that their estimates are subject to potential biases—as would be expected for a study undertaken during a public health emergency. For example, reliance on routine data collected by health-facility staff allows for conflation of missing health-indicator data with actual decreased use of health services. Similarly, estimating trends with crude indicators rather than rates (eg, facility-based deliveries per pregnancy) prevents differentiation between changes in need and changes in demand. For example, decreasing fertility rates, which conceivably could have occurred during the epidemic, would also result in crude reductions in antenatal care visits and facility-based deliveries. Additionally, as with all uncontrolled analyses, confounding due to an alternative, contemporary shock (eg, a vaccine stock out) cannot be excluded, but is unlikely. These concerns aside, Delamou and colleagues' results are robust across a range of indicators and offer an unmistakable reminder of the desperate need to maintain focus on rebuilding health systems in west Africa, Haiti, and other regions where epidemics receive immediate attention during disasters, but where focus is shifted when the news cycle moves on. Although the International Health Regulations7WHOInternational health regulations.http://www.who.int/ihr/publications/9789241580496/en/Google Scholar require high-income countries to help strengthen capacities to prevent emergencies, WHO's Contingency Fund for Emergencies8Gostin LO Ebola: towards an International Health Systems Fund.Lancet. 2014; 384: e49-e51Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar is severely underfunded, threatening the success of future responses. Such commitments to the global health community accomplish many shared goals, by preventing future epidemics while providing humanitarian aid consistent with international development goals.9Siedner MJ Gostin LO Cranmer HH Kraemer JD Strengthening the detection of and early response to public health emergencies: lessons from the west African Ebola epidemic.PLoS Med. 2015; 12: e1001804Crossref PubMed Scopus (48) Google Scholar Yet the greatest challenge has not been in realising the need for funding, but in convincing donor nations to provide funding for prevention and health-system strengthening, as opposed to in response to emergencies after they occur. In west Africa, the work of Delamou and colleagues should should prompt a thorough assessment of the causes of declines in health-care access after the epidemic. Were such declines caused by fear or mistrust,10Bausch DG Schwarz L Outbreak of Ebola virus disease in Guinea: where ecology meets economy.PLoS Negl Trop Dis. 2014; 8: e3056Crossref PubMed Scopus (205) Google Scholar deficiencies in human resources due to attrition and deaths related to Ebola virus disease,11Kilmarx PH Clarke KR Dietz PM et al.Ebola virus disease in health care workers—Sierra Leone, 2014.MMWR Morb Mortal Wkly Rep. 2014; 63: 1168-1171PubMed Google Scholar a basic shortage of health infrastructures, or, most likely, some combination of all these factors? Targeting the root causes, preventing future epidemics, and improving access to health services for the millions affected by weak public health infrastructure will require the international health community—countries and their implementing partners—to show unwavering commitment to the long, slow, collaborative work required for meaningful capacity building. Ending the epidemic showed what these partners were capable of, but their greatest responsibility has only just begun, and a failure in this responsibility will be seen, not just in missed vaccines or clinic visits, but also in lives lost. MJS receives funding from the National Institutes of Health (K23 MH099916) and the Harvard Center for AIDS Research (P30 AI060354). JDK declares no competing interests. Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort studyMost maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions. Full-Text PDF Open Access