Ebola: a holistic approach is required to achieve effective management and control.
Bottom Line: The scale of the epidemic has accelerated research efforts for diagnostics, treatment, and prevention galvanized through increased availability of funding.However, there is a long way to go.In this review we summarize the current knowledge, examine the sociocultural context in West Africa, and outline priority areas for future research.
Affiliation: The Medical Research Unit (MRC), Fajara, The Gambia.Show MeSH
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Mentions: For an outbreak to be effectively controlled and eventually come to an end, control measures need to be rapidly implemented to guarantee that each affected patient infects less than 1 case (R < 1). In the absence of licensed novel treatments and vaccines, control of the epidemic relies on nonpharmaceutical interventions, which include quick identification and isolation of cases, control measures in hospital settings, identification and follow-up of contacts, and, very importantly, safe burials. In the first Ebola epidemic several factors contributed to stopping transmission, including leadership and clear designation of authorities, organization, coordination (assuring international and local support), logistics, and communication.17 Several subsequent epidemics used field teams with experience in containing other outbreaks, such as measles or polio, to trace primary contacts of patients with Ebola because they are trained for rigorous identification and surveillance. Because the virus is not transmitted through air or water, stopping transmission should be feasible when the cases are detected early and managed properly.35 However, burials have effectively served as super-spreader events. Culturally sensitive burials and disposal of cadavers are needed.14 Efforts are ongoing to assess previously successful strategies in the current epidemic. Some mathematic models have quantified the risk of transmission stratified in the different contexts (ie, hospital and community15) and within the community between sick patients and burials.14 In the past, changes in behavior led to a significant reduction both in hospital-to-community and within-community transmission.17 However, reducing transmission in hospitals would not be enough now. The most effective means to control the current epidemic require a combined strategy of intensifying contract tracing to remove infected persons in the community at an early stage of the development of symptoms, provide both isolation and care,15 and achieve sanitary burials.14 Models predict that the epidemic could be stopped by full alignment of these strategies with an efficacy of 60% for each of them if all were implemented.14 If only individual strategies were applied, these would need to achieve greater than 90% efficacy to control the current outbreak in West Africa.14 The experience in developed countries has shown that with appropriate resources, case mortality of EV infection can be decreased.3 Because burials are key in the transmission of the virus, the improvement of clinical care that would lead to decreased mortality would favor control of the epidemic. Improvement in clinical care would also help re-establish the confidence of affected communities in health services. Fig 4 illustrates potential strategies and intervention points to achieve a holistic approach to Ebola control.
Affiliation: The Medical Research Unit (MRC), Fajara, The Gambia.