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  • Blue Ocean l 16-03-07 00:00:00 l View : 599
  • Science Magazine Feb 2016

    Beyond Ebola

    The Ebola epidemic provides lessons for how to respond to future epidemics

    By Janet Currie, Bryan Grenfell, Jeremy Farrar

     

    On 14 January 2016, Liberia was declared Ebola-free. A new case was identified shortly after the announcement, but it is nevertheless clear that the West African epidemic has moved on to a more hopeful phase. What lessons can be drawn from the Ebola crisis to help the international community to prepare for and respond to the next global epidemic? This question is particularly pertinent given the recent declaration of the Zika virus as a public health emergency.

    RESPECTFUL LOCAL HEALTH CARE. Over US$7 billion were raised for the Ebola response, and international efforts were made to supply personnel. But it was ultimately underequipped local workers on the ground who bore the brunt of the epidemic: More than 800 health care workers were infected, and more than 500 died. These facts underscore the importance of rebuilding and strengthening local health care and health surveillance networks, as well as building trust in both the health care system and political structures.

    In public remarks on the epidemic, Margaret Chan, the Director-General of the World Health Organization (WHO), stated that “when communities saw for themselves that hiding patients in homes could lead to the death of entire households, they found their own way to separate the healthy from the infected… These changes in community behaviours helped bring some of the earliest hotspots under control” (1). In fact, treating the rights of the infected and their families as secondary to the urgent need for infection control proved counterproductive: It undermined containment of the epidemic and led to the loss of more lives. Former Irish President Mary Robinson has argued that safeguarding the human rights of victims is essential to effective control of an epidemic (2).

    INTERNATIONAL RESPONSE. At the same time, a more efficacious, timely international response is essential. The first Ebola cases were confirmed in March 2014; just 2 months later, Médecins San Frontières declared the epidemic to be out of control. Yet, the WHO did not convene an international meeting on the outbreak and declare it a Public Health Emergency of International Concern (PHEIC) until August 2014. As the international body charged with responding to infectious disease outbreaks, the WHO must have the mandate, authority, and capacity to respond faster and with much greater impact.

    The need for reforms at the WHO has been stressed from several expert panels (3–6). All these panels have recommended the setting up of a dedicated Center for Health Emergency Preparedness and Response within the WHO, with an independent advisory group, transparent decision-making, and a protected budget that cannot be cannibalized for other issues. The WHO must also implement its existing mandate to require and assist countries to define and develop minimum core capacities for detecting and reporting outbreaks. The United Nations should oversee the progress of these initiatives and offer assistance, especially in fragile and failed states. Finally, research must be sustained and coordinated both between and during epidemics. The National Academy of Medicine frames these issues as matters of global security and estimates implementation costs of $4.5 billion per year (5).

    MULTIPLE PERSPECTIVES. Although the expert panels discussed above emphasize the need for coordinated research, their focus is mainly on biomedical disciplines. A more successful approach to future outbreaks needs to coordinate knowledge from many disciplines in two main ways. First, scientists must quantify and ideally predict the course of an epidemic from its zoonotic origins in reservoir species, through the course of the epidemic, to its wider effects on health systems and society. Second, every aspect of this research program needs to move beyond customary disciplinary silos, integrating insights from the natural sciences, public health, and clinical medicine with those from engineering, social science, and ethics.

    Three examples underline the multidisciplinary nature of the research challenge (see the table). First, the risk of zoonotic emergence must be mapped using innovative surveillance methods, data that track human movement, and computational methods (7). However, the risk of human contact and the emergence of disease also depend on economic and social factors such as travel, migration, and urbanization (8).

    Second, integrating data from genetic analysis of pathogens and medical surveillance into epidemiological models is a key step in understanding epidemic spread and the effects of control efforts. Understanding implications from molecular virology and immunology for the dynamics of population herd immunity is a crucial area for research. However, the Ebola epidemic has shown that social structures, living environments, and human behavior all shape the course of an epidemic (9). Understanding behavior change (and especially culturally appropriate ways to influence it) requires expertise from fields such as anthropology and psychology; without such insights, control measures can founder.