www .e l s e v i e r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Review
article
Ebola
hemorrhagic
fever
outbreaks:
strategies
for
effective
epidemic
management,
containment
and
control
Gerald
Amandu
Matua
a,∗,
Dirk
Mostert
Van
der
Wal
b,
Rozzano
C.
Locsin
caCollegeofNursing,SultanQaboosUniversity,Oman
bDepartmentofHealthStudies,UniversityofSouthAfrica,SouthAfrica cChristineE.LynnCollegeofNursing,FloridaAtlanticUniversity,FL,USA
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t
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c
l
e
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f
o
Articlehistory:
Received24October2014 Accepted13February2015 Availableonline17April2015
Keywords: Ebolavirus Filoviridaeinfections Ebolahemorrhagicfever Ebolaepidemics
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Ebolahemorrhagicfever,causedbythehighlyvirulentRNAvirusofthefiloviridaefamily,has becomeoneoftheworld’smostfearedpathogens.Thevirusinducesacutefeveranddeath, oftenassociatedwithhemorrhagicsymptomsinupto90%ofinfectedpatients.Theknown sub-typesofthevirusareZaire,Sudan,TaïForest,BundibugyoandRestonEbolaviruses.Inthe past,outbreakswerelimitedtotheEastandCentralAfricantropicalbeltwiththeexception ofEbolaRestonoutbreaksthatoccurredinanimalfacilitiesinthePhilippines,USAand Italy.Theon-goingoutbreakinWestAfricathatiscausingnumerousdeathsandsevere socio-economicchallengeshasresultedinwidespreadanxietyglobally.Thispanicmaybe attributedtotheintensemediainterest,therapidspreadofthevirustoothercountrieslike UnitedStatesandSpain,andmoreover,totheabsenceofanapprovedtreatmentorvaccine. Informedbythiswidespreadfearandanxiety,weanalyzedthecommonlyusedstrategies tomanageandcontrolEbolaoutbreaksandproposednewapproachesthatcouldimprove epidemicmanagementandcontrolduringfutureoutbreaks.Webasedour recommenda-tionsonepidemicmanagementpracticesemployedduringrecentoutbreaksinEast,Central andWestAfrica,andsynthesisofpeer-reviewedpublicationsaswellaspublished“field” informationfromindividualsandorganizationsrecentlyinvolvedinthemanagementof Ebolaepidemics.
Thecurrentepidemicmanagementapproachesarelargely“reactive”,withcontainment effortsaimedathaltingspreadofexistingoutbreaks.Werecommendthatforbetter out-comes,in additionto“reactive”interventions, “pre-emptive”strategiesalso needtobe instituted.Weconcludethatemphasizingboth“reactive”and“pre-emptive”strategiesis morelikelytoleadtobetterepidemicpreparednessandresponseatindividual, commu-nity,institutional,andgovernmentlevels,resultingintimelycontainmentoffutureEbola outbreaks.
©2015ElsevierEditoraLtda.Allrightsreserved.
∗ Correspondingauthor.
E-mailaddresses:gmatua@gmail.com,gamandu@squ.edu.om(G.A.Matua). http://dx.doi.org/10.1016/j.bjid.2015.02.004
Introduction
Ebolahemorrhagicfever(EHF)orEbolavirusdisease(EVD)is thehumandiseasecausedbyinfectionofthesinglestranded RNAvirusesofthegenus‘Ebola’andfamily‘Filoviridae’.Ebola viruswasdiscoveredin1976,followingcoincidingoutbreaks inZaire, nowDemocraticRepublicoftheCongo(DRC),and Sudan.1,2 EVDusually begins with an acute fever, causing deathfollowinghemorrhagicsymptomsinupto90%ofcases dependingontheviralspecies.1,2Theknownspeciesinclude BundibugyoEbolavirus(BEBOV),SudanEbolavirus(SEBOV),Zaïre Ebolavirus(ZEBOV),RestonEbolavirus(REBOV)andCôteD’Ivoire Ebolavirus(CIEBOV),alsoknownas,TaïForestEbolavirus(TAFV). TheREBOVstrainhascausednohumandeathssofar,buthas beenlethaltochimpanzees,gorillasandmonkeys.3,4
Intermsofpathogenicity,SEBOVstrainleadstocase fatal-ity rates of 40–60%, ZEBOV rates range from 60% to 90%, whilethe BEBOV strain is associated with fatality rates of 25%.The CIEBOV subtypehas been implicated in a single non-fatal human case.2,4 Generally, this high fatality rate, theinternationalspreadofthevirusacrossborders, includ-ing the possibleuse ofthe viralisolates asa possibletool forbioterrorismmakeEVDanimportantpublichealth con-cern of global proportions. Consequently, Ebola outbreaks lead towidespread fear, anguish and hysteria, locally and internationally,duetomediaattention,commerce,traveland tourism.3,5
Typically,EVDleadstorapidsuppressionoftheimmune system,triggeringsystemic inflammatoryresponsecausing impairedvascular, coagulationand immunesystems func-tioning,resultinginmultipleorganfailure,hypovolemicshock anddeath.2,5Sinceitsdiscoveryin1976,noeffectivevaccine or post-exposuretreatment exists to date.Hence, the cur-rentdiseasemanagementplanconsistsofsupportivetherapy torevive infected patients, minimizing infection transmis-sion,andcalminganxiouspopulations.2,3Theseinterventions oftenrequireinterdisciplinaryeffortsinstitutedatboth com-munityandhealthcareinstitutions.
Inthispaper,wediscusstheepidemiology,clinicalfeatures andmodeoftransmissionofEbolavirus.Wealsohighlight epidemicresponseefforts instituted inrecentoutbreaks in East,CentralandWestAfrica.Werecommendstrategiesfor improvedepidemicmanagementduringandin-between out-breaks.Thepaperisbasedonsynthesisoforiginalresearch and review papers indexed in MEDLINE, Scopus, PubMed, CINAHL,ScienceDirect,andGoogleScholardatabases, pub-lishedbetweenJanuary2000andSeptember2014,aswellas datacollectedduringadoctoralresearchstudyconductedin UgandabetweenJuneandJuly2013.
Toreflectcurrentpracticesandhighlightspecificaspects ofepidemicmanagement,wehavealsoincludedsubstantial amountsofrecent “field”informationfrom individualsand organizationsinvolvedintherecentoutbreaks, intheform ofonline resources, newspaperarticles, press releases and clinicalguidelines.Theresourcesandpublicationsusedwere obtainedfrom databasesusingcombinations ofthe Medi-calSubjectHeadings(MeSH)andrelatedsearchterms,“Ebola hemorrhagicfever”;“Ebolavirus disease”;“filoviridae infec-tions”; “Ebolaepidemics”; “communicable disease control”;
“case management”;“disease surveillance”;“epidemiology” and“diseasemanagement”.Peer-reviewedarticlespublished inthelastdecadeinEnglishthatfocusedonEbolaandMarburg wasprioritized.
Focus
of
the
study
ThisarticlebrieflyintroducesthereadertoEbolavirusdisease, thevariousstrainsandthecommonsignsandsymptomsof thedisease,includingcurrentepidemicmanagement strate-gies. Thepaper ends withrecommendations forimproved epidemicmanagementstrategiesbasedonthelessonslearnt fromoutbreaksinEast,CentralAfricaandWestAfrica.
Mode
of
transmission
TheexacttransmissionmodeofEbolavirusesfromtheir nat-ural reservoir tohumans ornon-human primates remains largely unknown,2,6 althoughmost outbreaksappear tobe zoonotic.Inlaboratoryanimals,theviruscaninitiate infec-tionfollowingingestion,inhalationorpassagethroughbreaks intheskin.4,7Innon-humanprimates,experimentshavealso shownthattransmissioncanoccurthroughdroplet inocula-tionofthevirusesintothemouthoreyes.8
Inhumans,outbreaksusuallyoccurfollowing person-to-persontransmissioninvolvingdirectcontactwiththemucous membranesorbrokenskinwithcontaminatedblood,vomitus, urine,feces,andsemenfrominfectedpersons.7,9During out-breaks,ithasbeenshownthatdirectcontactamonghumans occursduringfunerals,aspartofritualhandlingofcorpses, asamajormodeofinterfamilialtransmission.8,10Inaddition, healthcare workers are atrisk ofinfection if they carefor Ebolapatientswithoutappropriateprotectivemeasuresdue toshortagesandpoorinfrastructureorfollowingexposureto patientswithunrecognizedEbolavirusdisease.5,11
Contrary tothebelief thattheEbolavirus isconfinedto the rain forest ofCentral Africa, the on-going outbreak in WestAfrica3,11 hasshownthattheviruscanspreadrapidly andwidely,coveringlargeareas,inthiscaseGuinea,Liberia, Sierra Leone, Nigeria, Senegal, Mali, and USA. The factors implicatedinthisspreadarefear,denial,misinformation, mis-trust, concealment, and rumor. These resulted incontacts and infectedpersons to avoid or escapefrom surveillance systems ortreatment centers,3,11 orrelatives hiding symp-tomaticfamilymembersortakingthemtotraditionalhealers. Suchunregulatedmovementofinfectedpersonsacross bor-ders amplifies Ebolaepidemics, exacerbated byinadequate surveillancesystemsandmedicalisolationcenters,11,12 and persistent high-risk cultural practices like consumption of bushmeatandfuneralritualswherephysicalcontactoccurs withthedeceasedpatient.2,13
Inadditiontohumantohumancontact,directcontactwith infectedwild animalssuchasgorillasor chimpanzees dur-inghunting,butcheringandwhilepreparingmeathasbeen asignificantsourceofinfectiontohumansespeciallyinthe DRC,Gabon,andUganda.2,13Apartfromcontactwithinfected non-human primates,humanexposuretobatsecretionsor excretionshasalsobeendemonstratedtobeapotentialroute
foracquisitionofMarburgandEbolavirusesfollowingstudies doneintheDRCandUganda.14Duringepidemics,nosocomial infectionassociatedwithmedicalproceduressuchas intra-venoussiteinsertionsandsurgerieshaveamplifiedfilovirus epidemics, especiallywhererules ofuniversal precautions, barriernursing,andinfectioncontrolarenotwellobserved.5,9 These examples further demonstrate that transmission of Ebolavirusescanoccurthroughcontaminated patientcare equipmentandsupplies.Ebolavirushasalsobeentransmitted followingaccidentalinfectionofworkersinBiosafety-Level-4 (BSL-4)facilitiesduringinvestigationalstudies.15These trans-mission modes and observations inUganda, the DRC, and West Africaconfirm thatlargeEbola epidemicsoccur after patientsenterweakhealthcaresystems,wherebarrier nurs-ingandepidemicmanagementpracticesareinadequatedue tothelackoffacilities.5,12,13
Clinical
manifestations
Infectedpatientspresentwithsevereheadache,shivers,sore throat, muscle aches, weakness and hiccups in the early stagesoftheillness,followinganincubationperiodof2–21 days.6,16 As the disease progresses, patients develop nau-sea,vomiting,difficultbreathing,abdominalpain,diarrhea, pharyngitis, conjunctivitis,organ dysfunction, hypovolemic shock,andbleedingfrombodyorificesandintravenous injec-tionsites,eventuallyendingupindeath.2,8Forsurvivors,the processofrecoveryisveryslow,characterizedbycomplaints ofsevere lossofweight, scalyskin,lossofappetite,sexual weaknessandinflammationofthetestesinmalesurvivors. Inaddition,visualandhearingdifficulties,tiredness,mental stress,muscleand bonepains, includingmenstrual distur-bancesinfemalesurvivors,arealsocommon.2,8,9
Strategies
for
effective
epidemic
management
and
containment
ThemanagementofEbolaoutbreaks continuestobe com-plicated by several challenges and shortcomings. These difficulties relateto clinical management of patients, con-tacttracing,diseasesurveillance,logistics,laboratorytesting, communication, resistance, panic and hysteria in affected populations.Thisisfurthercomplicatedbythefactthatthe naturalreservoir ofthevirus remains unknown,2,6 thereby negativelyimpactingprimaryprevention.
Inabsenceofprimaryprevention,epidemicmanagement focusesmainlyoneducatingthemassesandinstituting sec-ondary strategies during outbreaks and in the aftermath. Thesuccessofsecondarypreventionstrategiesrequiresgood understanding ofthe public’s views about Ebola as a dis-ease. Understandingpeople’sviews and perspectives helps healthworkers,governmentofficialsanddevelopment part-nerstodesigneffective approaches toeducate the masses aboutEbolaanditseffects,includinghowtodealwithitssocial consequences.9,17,18
Thelearntlessonsfrompreviousoutbreaksindicatethat incorporatingcommunity’sperspectivesandbeliefshelpsin gainingtheirsupportandtodemystifytheepidemic, result-inginreducedfear,panic andantisocialsentimentsduring
anEbolaoutbreak3,16,19Infact,incorporatingtheperspectives oflocalpopulationsintonationalepidemicresponseefforts, withsupportfrominternationalandlocalexpertsandlocal andinternationalpartners,leadstobetterepidemiccontrol, particularlyinresourcechallengedenvironments.11,17,19
Currently,themostdominantoutbreakmanagement strat-egymaybeclassifiedas“postoutbreakinterventions”.However, the continuingoutbreaks inEast, Central and West Africa demonstrates theurgent needforhealthworkers, interna-tional agencies,development partnersand governmentsto institutenotonlytheusual“postoutbreakinterventions”,butto alsoemphasizeadditionalresponsestrategies,whichwerefer hereas“constantinterventions”.Thisstrategypermitsdealing withtherealityandthreatofEboladecisivelyandeffectively. “Postoutbreak interventions” are “reactive” actions under-taken atcommunity or institutional levels to mitigate the spreadofon-goingepidemics,while“constantinterventions”are “pre-emptive”stepstakenatindividual,communityand insti-tutional levelstoboostpreparednessand readinesstodeal withfutureepidemics.“Constantinterventions”canhelpto sig-nificantlyboosthealthworkers’understandingofthehuman aspectsoftheillness,byilluminatinghiddenaspectsofwhat theillnessmeanstothelocalsandhowtheirnotionsabout Ebolablendwithculturalbeliefsandpracticesandhowthese impactepidemicresponsesinthefuture.20
Post
outbreak
interventions
Post outbreak interventions are “preventive and corrective measures” instituted by epidemicresponse teams oncean outbreakhasbegun.Itaimstopreventfurtherspreadof infec-tion,andencourageindividualsandcommunitiestoengage inactivitiesthatcanslowandhaltthespreadofthevirus.21 Theinterventionsvarywidelyfrombasichygienicpractices suchashandwashingandcleaningofclothingandhunting toolstopropercookingofmealsespeciallyofmeatproducts, all to minimize contamination. The strategy also empha-sizes timely case management as well as mobilization of communitiesin at-risk areasagainst consumptionofbush meat,includingwildhoofedanimals,primates,rodentsand bats.6,11,21
Post outbreak interventions further encourages timely identification of probable patients, transferring suspects to designated medical facilities, monitoring suspects and enforcinginfectioncontrolmeasuresinhealthfacilitiesand communities.Whenproperlyimplemented,thisstrategy con-siderably slows down epidemics, eventually leading to its mitigation.2,10,17InrecentoutbreaksinEast,CentralandWest Africa,thepostoutbreak interventionsusedmaybe classi-fiedunderactivediseasesurveillance,laboratoryconfirmation,case management,socialmobilization,educationandtraining,resource mobilizationaswellascommunication.
The practice of ‘active disease surveillance’ encourages healthcarepractitionersworkinginurbanandrural commu-nitiesandhospitalstodocument,report,andpromptlyrefer contacts to isolationcenters, ensuring swift detection and controlofnewinfections.Thiscase-by-casereportingof ‘sus-pects’tonationalorregionalEbolaresponseteamsallowstheir
promptfollow-upandreferraltoisolationcenters,aswellas toassessthescopeoftheepidemic.2,20
Theinterventionof‘laboratoryconfirmation’ ismandatory whenanepidemicissuspected,uptothepointwherethe epi-demicisconfirmedandthendiagnosiscanbebasedonclinical manifestations.8–10Settingupafield-screeninglaboratoryto handlesamplessafely,securelyandtimely ismandatoryto facilitate prompt diagnosis and to guide mode of patient care.10,18
Themode of‘casemanagement’ dependson whetherthe patientbelongstothesurveillancecategoriesof“alert”, “sus-pect”,“probable”or“confirmed”;whichrangesfromsuspected contactwithaninfectedpersontolaboratoryconfirmationof Ebolainfection.When apersonisdeclared“confirmed”case, theyareimmediatelyisolated,followedbyspeedyinitiationof supportivetherapy.9,19Whenthepatientmakesfullrecovery, properdischargeismandatorytoensurethatthereis unhin-deredreintegrationbackintotheirhomecommunities,which normallyoccursduetofearandstigmafollowingthe hospital-izationofEbolapatientsandcontacts.10,11Casemanagement alsoinvolvesestablishingsafeburialpractices,19,20including identifyingsuitableburialgrounds,trainingburialteamsand developingguidelines toensure safeburial.22 Further,case managemententailsensuringthatnodirectcontactoccurs withthedeceasedandburialsarerestrictedtotrainedteams infullpersonalprotectiveequipment.10,19
Thesteps of“social mobilization” are employed to facili-tatemultisectoralcollaboration,epidemicpreparednessand response because of the ability to influence both health workers and community members to actively participate in epidemic control.18,23,24 The media has been used for socialmobilization,especiallylocalradiostationstoeducate communitiesforrapidandmeaningfulresponseinaffected areas.9,10 Socialmobilization hasalsoincorporatedthe use ofcommunitydramagroups atpublicplacessuchas mar-kets,schoolsandworshipplacestoattractmassattentionand thentopasskeymessagestowinpeoples’confidence, includ-ingfightingsocialstigma.20Documentaryfilmsandeducative postershavebeen usedtodiscourage“high-risk”practices, suchashandshakes,largegatherings,healingpracticesand traditionalburialritualstocurtailratesofinfectionand pro-moteepidemicresponse.10,22,24
Educating and training healthcare practitioners and community resource persons during outbreaks has been anothermajorinterventionemployedtoprepare communi-tiestoparticipateinsurveillanceandepidemicmanagement activities.19,22Thisinterventionisvitalbecausecorrect man-agementofepidemiccontrolactivitiesleadstoappropriate community response.10,22,25 Besides providing information about epidemic response, “personal safety training”, is also emphasizedwithspecialfocusonsafewearingandremovalof full-bodyequipment.Thetrainingalsoemphasizesthe“buddy system”ofworkinginpairs,wherecolleagueswatchovereach other, when wearing protective gears and when providing patientcaretoensurenostepsaremissedandtheirsafetyis guaranteed.21,22,26Theeducationandtrainingsessionsensure thatthereisbothknowledgeandreadinesstorespondto on-goingepidemics.
Resourcemobilizationafteranoutbreakisvitalbecause thefightagainstEbolaepidemicsishighlyresourceintensive.
Thismaybeinformofmedicalandsupportstaff,finances, vehicles, food, clothing, personal items or as hospital and laboratory equipment and supplies.8,9,27 To succeed in resourcemobilization,thereisneedformultisectoral collab-orationbetweenordinarycitizens,civilsocietyorganizations, political and faith based organizations, as well as local and international development partners and government departments.10,27,28
Anothervitalaspectofepidemiccontrolthatsignificantly affectstheoutcomeofoutbreakmanagementisthe commu-nicationstrategy.Fieldexperiencesfrompreviousoutbreaks indicatethatepidemicrelatedinformationshouldbe commu-nicatedtothepublicinwaysthatbuild,maintainorrestore trustandrespectlocalculturesandcountrynorms.29,30 Infor-mation sharing betweenstakeholders,suchasgovernment departments,developmentpartners,religiousbodies,training institutions,localleadersandthepublicleadstotimely inter-ventions. Improvedcommunication isthuscritical because it facilitatesresource identificationand mobilization,social mobilization, education andtraining,surveillance andcase managementaswellashelpingtore-integratesurvivorsand contactsintofamilies.19,27,28
Akeyelementofimprovedcommunicationisearly integra-tionandinvolvementofthemediatohelpwithshapingthe public’sperceptionabouttheepidemicandtoeducatethemon diseasepreventionandcontrolmechanisms.18,27,28Improved communicationalsonecessitiesobligingmediaagencies,both localandinternationalmediaoutlets,tocommunicate,tothe publicinatimelymanner,vitalepidemicinformationinways thatinstilconfidenceandnotfear,encouragingand mobiliz-ingkeystakeholdersinthecommunity,countryandgloballyto respondtoanyhealththreats,includingactivelycontributing tooutbreakmanagement.18,30,31
Earlyinvolvementofthemediawasnotedtoresultinmore accurateand timelyreporting,16,18,19 creatingawarenessfor infectionprevention.Thisinturnpromptscommunityaction including rushing suspectedcases toisolation centers.10,19 Thisincreasedawarenessalsoencouragesindividualstoavoid contactwith‘suspect’casesandinspiresbettercompliance withandsupportforepidemiccontrolguidelinesleadingto mitigationoftheepidemic.19,27,31
Constant
interventions
In additionto thereactive, ‘postoutbreak interventions’,that characterizescurrentepidemicmanagement,weproposethat thecontinuedsporadicoccurrenceofEbolaepidemicsinEast, CentralandWestAfricarequiresamoreholisticwaytodeal withthethreatoftheepidemic.Wesuggestastrategy con-sistingof“pre-emptive”steps, termed,‘constant interventions’ approach,thatshouldbeundertakenatindividual, commu-nityandinstitutionallevelsfollowinganepidemicandtobe continuedintheaftermath,thatisin-betweentheoutbreaks. Emphasizing such “pre-emptive” strategy is likely to improvetheepidemicreadiness,particularlythatof“at-risk” populationsandgovernmentagenciesin‘high-risk’countries. Whenproperlyimplemented,suchholisticmeasureshelpto enhance theknowledgerelated toEbolaoutbreaks,as well as preparedness and readiness of populations, healthcare
institutionsandkeygovernmentdepartmentstorespondin atimelymannershouldanepidemicemerge.
In essence, ‘constant interventions’ are intended to keep populationsandinstitutionsin‘high-risk’areasready,fully preparedandconstantlyawareoftheriskofEbolaoutbreak recurrence. Such preparedness is likely to result in rapid epidemic responseshould an outbreak occur, considerably enhancingthepossibilityoftimelyepidemiccontrol.We rec-ommendthat the“constantinterventions” strategyemployed shouldbe informed bythepublic’s perceptionsand beliefs aboutEbolaandshouldaddressanygapsthatexistintheir understandingoftheillness.Thisimpliesthatinterventions carriedoutin-betweenoutbreaksshouldberelevantand evi-dence based,18,19 further maintaining that during “constant interventions”,healthteamsshouldaddress misinformation, rumors,beliefs,andpeoples’peculiarexperienceswith previ-ousEbolaoutbreaks.Thisisvitalnotonlyfor“neutralizing” negativeperceptionsabout Ebolaandits management, but ratherto helpin confidencebuilding and motivating com-munitiesto trustmoreinthe healthcareworkersand the outbreakrelatedservices.19,27,31
Preferably,theseinterventionsshouldbeimplementedat bothindividualandfamily(humanormicro)andinstitutional and governmental (macro) levels. This “binary” approach hasthe capacityto enhanceindividuals’, families’, institu-tions’ and countries’ epidemic preparedness and response intheeventofnewoutbreaks.The“constantinterventions”at individual/family(micro)levelshouldfocuslargelyon infor-mationprovision,sharingbestpracticesandhealtheducation to increase knowledge levels.19,31 In contrast, at govern-mental/institutional(macro)level,the“constantinterventions” shouldseektoimprovethecapacityandreadinessofvarious departmentsthatusuallyprovideessentialservicesrequired torespondtooutbreaks.
We recommend that to enhance institutional effective-ness, health practitioners in ‘at-risk’ areas and countries needtobekeptconstantlyup-to-datewithcurrentepidemic responsestrategies,reinforcedthroughregularseminarsand workshops.18The“constantinterventions”strategyensuresthat health institutions infrastructure are “epidemicready”. This readinessentailsmakingsignificantimprovementsinhealth facilityinfrastructuresuchasimprovingisolationunits, diag-nosticlaboratoriesandinstitutinginfectioncontrolfacilities and procedures.10 Such interventions are particularly vital inEbolaproneareasofEast,CentralandWestAfricawhere sporadicoutbreakshaveoccurred.11,19Whenproperly imple-mented,these“constantinterventions”canensurethathealth workers, community leaders and the public are properly informed about the true nature of Ebolaincluding recom-mendations foroutbreak containment aimed atearly case detection, reportingand clinical management. These inter-ventions also ensure that vital health and related service institutions inat-risk communities and countries are fully preparedandreadytorespondtoanimminentepidemic.
Conclusions
Ebolavirusdiseaseisaseriouspublichealthconcernbecause of its frightening nature and the large number of deaths
associated with it, resulting from multi-organ and multi-system failure and hypovolemic shock.2,6,9 Currently, no globally approved treatment or vaccine exists. This lack hascontributedtothefailuretocontroltheon-goingEbola outbreaks affecting large parts of West Africa, despite effortsofaglobalcoalitioncoordinatedbytheWorldHealth Organization.3,11 The scale of the outbreak has pressured world players and the pharmaceuticalplayers to speed up the humantrials ofavailablecandidate vaccines,3,32,33 and necessitatedthe useofpreviouslyuntesteddrugsonEbola patients,34leadingtounprecedentedethicalchallenges.35,36 In the absence of a recognized definitive vaccine and treatment, the best optionto dealwith Ebolaoutbreaks is designingmoreresponsiveapproachestomanageon-going epidemicsandtopromoteepidemicpreparednessand readi-ness among individuals, non-governmental organizations andgovernmentdepartmentsinhigh-riskcountries.2,18,19
InEbolaproneareasandparticularlyduringoutbreaks,itis vitallyimportantthathealthworkers,internationalagencies, developmentpartnersand governmentsestablish epidemic managementstrategiesearlyandsucheffortsshouldcontinue wellintotheaftermathofoutbreaks.Incorporatingboth“post outbreakinterventions”and“constantinterventions”offersareal chanceforhealthteamsand governmentstodealwiththe threatofanon-goingandfutureEbolaoutbreaksinatimely anddecisivelyway.Theadvantageofthis“binary”approach isthatwhile“postoutbreakinterventions”enhance communi-tiesandhealthcareinstitutions’capacitytomitigatefurther spreadofanon-goingepidemic,the‘constantinterventions’at individual,communityandinstitutionallevelsdeepentheir understanding about Ebola, thereby enhancing overall epi-demicpreparednessandresponse.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Ethical
approval
UniversityofSouthAfrica:HSHDC/116/2012.UgandaNational CouncilofScienceandTechnology:SS3146.
Acknowledgements
Theauthorsacknowledgethatthisworkarosefromadoctoral thesissubmittedtotheUniversityofSouthAfrica,UNISA.The authorsalsoexpresstheirgratefulnesstotheUniversityfor the Bursaryawardedtotheprimaryauthor tofacilitatehis finalyeardoctoralstudies.
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