The west Africa Ebola virus disease outbreak: 10 years on
Authors: Henry Kyobe Bosa, Neema Kamara, Merawi Aragaw, Misaki Wayengera, Ambrose Talisuna, James Bangura, Henry G Mwebesa, Patrick D M C Katoto, Robert Kwame Agyarko, Chikwe Ihekweazu, Abdoulaye Bousso, Obasanya Joshua, Moussa Douno, Mosoka P Fallah, James Sylvester Squire, Tolbert Geewleh Nyenswah, Thelma V Nelson, Justin Maeda, Tajudeen Raji, Mamadou Souncalo Traoré, Olushayo Oluseun Olu, Yonas Tegegn Woldemariam, Benjamin Djoudalbaye, Ngashi Ngongo, Francis Chisaka Kasolo, Placide Mbala, Ibrahima Socé Fall, Ahmed Ogwell Ouma, Jean Kaseya, Jane Ruth Aceng
Journal: The Lancet Global Health (2024)

On March 23, 2014, the Guinean Ministry of Health, in line with the International Health Regulations 2005, notified WHO and the world of an outbreak of Ebola virus disease (EVD). This followed laboratory confirmation of the disease by the Pasteur Institute in Dakar, Senegal (a WHO collaborating centre), in a 16-year-old girl from Guéckédou, a small village in southern Guinea.1Ohimain EI Silas-Olu D The 2013–2016 Ebola virus disease outbreak in West Africa.Curr Opin Pharmacol. 2021; 60: 360-365Crossref Scopus (11) Google Scholar This was 10 years ago. For the first time, an EVD outbreak had occurred beyond central Africa.1Ohimain EI Silas-Olu D The 2013–2016 Ebola virus disease outbreak in West Africa.Curr Opin Pharmacol. 2021; 60: 360-365Crossref Scopus (11) Google Scholar Like earlier outbreaks since 1976, it happened in a remote setting with no indication that six African countries would later be affected. The outbreak started in late 2013 but was only confirmed months later in 2014. It spread from Guinea to Liberia, Sierra Leone, Mali, Senegal, and Nigeria. After 28 months, the outbreak had resulted in 28 652 cases and 11 325 deaths. Of the dead, 518 (5%) were health-care workers.1Ohimain EI Silas-Olu D The 2013–2016 Ebola virus disease outbreak in West Africa.Curr Opin Pharmacol. 2021; 60: 360-365Crossref Scopus (11) Google Scholar There were substantial socioeconomic effects in the three heavily affected countries (Guinea, Liberia, and Sierra Leone), where an estimated US$2·2 billion in gross domestic product was lost in 2015 and progress in the Sustainable Development Goals was reversed.2Onyekuru NA Ihemezie EJ Ezea CP Apeh CC Onyekuru BO Impacts of Ebola disease outbreak in West Africa: implications for government and public health preparedness and lessons from COVID-19.Sci Afr. 2023; 19e01513Google Scholar The combined direct economic burden and the indirect social impact was estimated to be $54 billion between 2014 to 2016.2Onyekuru NA Ihemezie EJ Ezea CP Apeh CC Onyekuru BO Impacts of Ebola disease outbreak in West Africa: implications for government and public health preparedness and lessons from COVID-19.Sci Afr. 2023; 19e01513Google Scholar The slow national, regional, and global level response, including the delays in detection of the outbreak, forecasting, and preparation by neighbouring countries; the initial culturally insensitive community engagement and poor compliance of communities with regard to safe burial practices; the misconceptions about the cause or cure of EVD; and the limited resources coupled with weak health systems fuelled the initial exponential transmission in the region.3Matson MJ Chertow DS Munster VJ Delayed recognition of Ebola virus disease is associated with longer and larger outbreaks.Emerg Microbes Infect. 2020; 9: 291-301Crossref PubMed Scopus (14) Google Scholar Countries with stronger health-care systems and stronger public health leadership—ie, Nigeria, Mali, and Senegal—quickly interrupted transmission following the transborder spillover. The overall response was largely reactive and inappropriately designed in the three most affected countries. In addition, there were large-scale deployments of individuals with no previous experience in EVD outbreak response. To control the unfolding situation, the UN Secretary-General set up the UN Mission for Ebola Emergency Response in 2014 to strengthen coordination and scale up response efforts. There were massive deployments by several organisations including WHO, and for the first time the Africa Union (AU), under the AU Support to the Ebola Outbreak in West Africa initiative, deployed 824 health specialists, among other agencies. Major reforms and landmarks in global public health emergency preparedness and response have emerged since this outbreak. The WHO Health Emergencies Programme was established on July 1, 2016, at the request of the World Health Assembly. Further, WHO introduced two initiatives: the Joint External Evaluation (JEE), a voluntary, collaborative, multisectoral process that evaluates a country's capacity to manage health emergencies; and the National Action Plans for Health Security, an overarching national health security plan that follows JEE recommendations. The outbreak accelerated the establishment of the Africa Centres for Disease Control and Prevention in 2016 to strengthen AU Member States' early detection of public health events, emergency preparedness, and response capabilities.4Member States of the African UnionStatute of the Africa Centres for Disease Control and Prevention (Africa CDC).Afr Yearb Int Law. 2019; 24: 363-379Crossref Scopus (0) Google Scholar As a result, a new framework known as the New Public Health Order emerged (panel). To date, 17 countries in Africa have fully developed National Public Health Institutes, with many others in different stages of development.5Taame Desta H Mayet N Riolexus Ario A Tajudeen R Role of National Public Health Institutes for a stronger health system in Africa.Fortune J Health Sci. 2022; 05: 603-609Crossref Google ScholarPanelKey recommendations that require urgent attention and investment to mitigate the effects of future Ebola virus disease outbreaks in Africa•Fully implement the New Public Health Order Framework of action to:•Establish functional national public health institutions•Strengthen the capacities and capabilities of public health workforces including community health workers•Enhance access through expansion and scale-up of manufacturing within Africa of medical countermeasures (diagnostics, therapeutics, vaccines, and other health products•Increase domestic financing towards self-sustenance and reduction of donor dependence•Foster respectful partnerships between nations, research institutions, manufacturing, philanthropists, donors, and recipient communities•Expedite the review of the International Health Regulations to ensure equity across countries in access to tools, technology, data, information, and other essential biological materials for effective pandemic preparedness, response, and resilience•Increase domestic financing through innovative mechanisms to sustain the prevention, preparedness, and response agenda to Ebola virus disease and other emerging infectious diseases•Explore the inclusion of risk transfer tools and instruments such as reserve funds, contingent credit facilities, catastrophe bonds, insurance, and re-insurance for sustainable finance•Fast track the operationalisation of the Africa Epidemics Fund to support preparedness and response efforts to combat public health threats•Develop and deploy early detection systems and tools that incorporate laboratory markers, and avail affordable diagnostic capabilities to characterise a broader range of febrile illnesses•Facilitate the establishment of a global pandemic accord that will foster collaboration, transparency, resilience, and accountability in handling public health emergencies•Institutionalise routine public health risk mapping and forecasting techniques, including regular capacity and readiness assessments of public health risks•Prioritise improved sepsis management and supportive care through development of new diagnostics and better implementation of existing tools, trained staff, and available supplies•Deliver community engagement and mobilisation tools that are mindful of cultural context to address misinformation (particularly about superspreader scenarios), stigma, discrimination, and misconception, as well as misinformation about what causes Ebola virus disease and how it can be cured•Invest in understanding the Ebola virus reservoir and human–animal behavioural dynamics•Break the existing silos and bottlenecks in the implementation of the One Health concept and foster collaboration, communication, and coordination between human health, animal health, and the environment•Define, map, and vaccinate the most at-risk communities before outbreaks•At-risk countries need to adopt multicountry adaptive clinical trial platforms for advancement of medical countermeasure research and development •Fully implement the New Public Health Order Framework of action to:•Establish functional national public health institutions•Strengthen the capacities and capabilities of public health workforces including community health workers•Enhance access through expansion and scale-up of manufacturing within Africa of medical countermeasures (diagnostics, therapeutics, vaccines, and other health products•Increase domestic financing towards self-sustenance and reduction of donor dependence•Foster respectful partnerships between nations, research institutions, manufacturing, philanthropists, donors, and recipient communities•Expedite the review of the International Health Regulations to ensure equity across countries in access to tools, technology, data, information, and other essential biological materials for effective pandemic preparedness, response, and resilience•Increase domestic financing through innovative mechanisms to sustain the prevention, preparedness, and response agenda to Ebola virus disease and other emerging infectious diseases•Explore the inclusion of risk transfer tools and instruments such as reserve funds, contingent credit facilities, catastrophe bonds, insurance, and re-insurance for sustainable finance•Fast track the operationalisation of the Africa Epidemics Fund to support preparedness and response efforts to combat public health threats•Develop and deploy early detection systems and tools that incorporate laboratory markers, and avail affordable diagnostic capabilities to characterise a broader range of febrile illnesses•Facilitate the establishment of a global pandemic accord that will foster collaboration, transparency, resilience, and accountability in handling public health emergencies•Institutionalise routine public health risk mapping and forecasting techniques, including regular capacity and readiness assessments of public health risks•Prioritise improved sepsis management and supportive care through development of new diagnostics and better implementation of existing tools, trained staff, and available supplies•Deliver community engagement and mobilisation tools that are mindful of cultural context to address misinformation (particularly about superspreader scenarios), stigma, discrimination, and misconception, as well as misinformation about what causes Ebola virus disease and how it can be cured•Invest in understanding the Ebola virus reservoir and human–animal behavioural dynamics•Break the existing silos and bottlenecks in the implementation of the One Health concept and foster collaboration, communication, and coordination between human health, animal health, and the environment•Define, map, and vaccinate the most at-risk communities before outbreaks•At-risk countries need to adopt multicountry adaptive clinical trial platforms for advancement of medical countermeasure research and development Since the west African EVD outbreak of 2014–16, other EVD outbreaks have been reported from Guinea (n=1), DR Congo (n=8), and Uganda (n=1).6US Centers for Disease Control and PreventionHistory of Ebola disease outbreaks.https://www.cdc.gov/vhf/ebola/history/chronology.htmlDate accessed: March 10, 2024Google Scholar The 2018–20 EVD outbreak in DR Congo and the COVID-19 pandemic subsequently revealed the inadequacies in the response mechanisms, persisting vulnerabilities, and substantial inequities in the public health emergency response architecture.2Onyekuru NA Ihemezie EJ Ezea CP Apeh CC Onyekuru BO Impacts of Ebola disease outbreak in West Africa: implications for government and public health preparedness and lessons from COVID-19.Sci Afr. 2023; 19e01513Google Scholar, 7Lucero-Prisno 3rd, DE Adebisi YA Lin X Current efforts and challenges facing responses to 2019-nCoV in Africa.Glob Health Res Policy. 2020; 5: 21Crossref Scopus (73) Google Scholar, 8Guetiya Wadoum RE Sevalie S Minutolo A et al.The 2018–2020 Ebola outbreak in the Democratic Republic of Congo: a better response had been achieved through inter-state coordination in Africa.Risk Manag Healthc Policy. 2021; 14: 4923-4930Crossref PubMed Scopus (9) Google Scholar These inadequacies include an insufficiently skilled health workforce, weak coordination systems, legislative and regulatory mechanism limitations, inequity of access to medical commodities, insufficient finances, and the narrow scope of medical countermeasures. Even though some candidate medical countermeasures have been tested in phase 1 and 2 clinical trials, intra-outbreak implementation of phase 3 clinical trials remains a challenge in EVD-affected countries, and there are no pre-approved protocols for phase 3 research to be implemented during an ongoing outbreak.9Aceng JR Bosa HK Kamara N et al.Continental concerted efforts to control the seventh outbreak of Ebola Virus disease in Uganda: the first 90 days of the response.J Public Health Africa. 2023; 142735Google Scholar The perpetual and fundamental challenges observed in the past 10 years need to be urgently addressed.10Ndembi N Aluso A Habtemariam MK et al.African leadership is critical in responding to public health threats.Nat Commun. 2024; 15: 877Crossref Scopus (1) Google Scholar As highlighted in the panel, we call for the following: sustainable, sufficient, and continued funding for health security; advances in the establishment and strengthening of national public health agencies; and substantial investments in preparedness, prevention, and response capabilities that can be used for local outbreaks and scaled for epidemics and pandemics. As witnessed in the 2022 EVD outbreak in Uganda, a swift response was possible amidst multiple urban spillover cases, undefined transmission lines, and delayed detection. Thus, Africa has the means, will, and capacity to avert the worst-case scenarios that can lead to substantial human losses and socioeconomic disruptions. We declare no competing interests.