PERS PE C T IV E Ebola Underscoring Global Disparities Ebola Underscoring the Global Disparities in Health Care Resources Anthony S Fauci M D A n outbreak of Ebola virus disease EVD has jolted West Africa claiming more than 1000 lives since the virus emerged in Guinea in early 2014 see figure The rapidly increasing numbers of cases in the African countries of Guinea Liberia and Sierra Leone have had public health authorities on high alert throughout the spring and summer More recent events including the spread of EVD to Nigeria Africa s most populous country and the recent evacuation to the United States of two American health care workers with EVD have captivated the world s attention and concern Health professionals and the general public are struggling to comprehend these unfolding dynamics and to separate misinformation and speculation from truth EVD originally identified in 1976 in Yambuku Zaire now the Democratic Republic of Congo and Nzara South Sudan is caused by an RNA virus in the filovirus family Ebola named after a river in Zaire encompasses five separate species Zaire ebolavirus Bundibugyo ebolavirus Ta Forest ebolavirus Sudan ebolavirus and Reston ebolavirus Reston ebolavirus is not known to cause disease in humans but the fatality rates in outbreaks of the other four species have ranged from 25 to 90 1 The strain currently circulating in West Africa bears 97 homology to Zaire ebolavirus samples found in the Democratic Republic of Congo and Gabon 2 This strain has historically resulted in the highest mortality 90 although the estimated case fatality rate in the current outbreak is less than 60 3 Outbreaks probably originate from an animal reservoir and possibly involve additional intermediary species The most likely A reservoir appears to be a fruit bat although that linkage has not been confirmed 1 Transmission to humans may have occurred through direct contact with tissue or bodily fluids from an infected animal Notably Ebola virus is a zoonotic pathogen and its circulation among humans is uncommon which explains the intermittent and unpredictable nature of outbreaks In fact although the virus has caused more than 20 outbreaks since its identification in 1976 it had caused fewer than 1600 deaths before 2014 with case counts ranging from a handful to 425 in the Ugandan outbreak of 2000 and 2001 3 In most instances the virus emerged in geographically restricted rural regions and outbreaks were contained through routine public health measures such as case identification contact tracing patient isolation and quarantine to break the chain of virus transmission B No of Cases and Deaths 2000 Guinea 506 cases 373 deaths Sierra Leone 730 cases 315 deaths Liberia 599 cases 323 deaths 1500 Cases Deaths 1000 500 0 Nigeria 13 cases 2 deaths April 2014 May 2014 June 2014 July 2014 Ebola Virus Cases and Deaths in West Africa Guinea Liberia Nigeria and Sierra Leone as of August 11 2014 Panel A and Over Time Panel B Data are from the World Health Organization www who int csr don archive disease ebola en 1084 n engl j med 371 12 nejm org september 18 2014 The New England Journal of Medicine Downloaded from nejm org at WEILL CORNELL MEDICAL LIBRARY on November 10 2014 For personal use only No other uses without permission Copyright 2014 Massachusetts Medical Society All rights reserved PE R S PE C T IV E Ebola Underscoring Global Disparities Frequency of Symptoms Reported in 103 Cases of Ebola Virus Disease in Kikwit Democratic Republic of Congo in 1995 Percent of Patients with Symptom Symptom Fever 90 Weakness 80 90 Diarrhea 80 90 Nausea and vomiting 70 80 Abdominal pain 60 70 Headache 50 60 Sore throat odynophagia dysphagia 50 60 Arthralgia or myalgia 50 60 Anorexia 40 50 Rash 10 20 Bleeding Any type 40 50 Gingival 10 20 Hematemesis 10 20 Melena 0 10 From puncture sites 0 10 Hemoptysis 0 5 The sample included 84 patients who died and 19 who survived representing approximately one third of the total cases in the outbreak Adapted from Bwaka et al 4 In early 2014 EVD emerged in a remote region of Guinea near its borders with Sierra Leone and Liberia Since then the epidemic has grown dramatically fueled by several factors First Guinea Sierra Leone and Liberia are resource poor countries already coping with major health challenges such as malaria and other endemic diseases some of which may be confused with EVD Next their borders are porous and movement between countries is constant Health care infrastructure is inadequate and health workers and essential supplies including per sonal protective equipment are scarce Traditional practices such as bathing of corpses before burial have facilitated transmission The epidemic has spread to cities which complicates tracing of contacts Finally decades of conflict have left the populations distrustful of governing officials and authority figures such as health professionals Add to these problems a rapidly spreading virus with a high mortality rate and the scope of the challenge becomes clear Although the regional threat of Ebola in West Africa looms large the chance that the virus will establish a foothold in the United States or another high resource country remains extremely small Although global air transit could and most likely will allow an infected asymptomatic person to board a plane and unknowingly carry Ebola virus to a higher income country containment should be readily achievable Hospitals in such countries generally have excellent capacity to isolate persons with suspected cases and to care for them safely should they become ill Public health authorities have the resources and training necessary to trace and monitor contacts Protocols exist for the appropriate handling of corpses and disposal of biohazardous materials In addition characteristics of the virus itself limit its spread Numerous studies indicate that direct contact with infected bodily fluids usually feces vomit or blood is necessary for transmission and that the virus is not transmitted from person to person through the air or by casual contact Isolation procedures have been clearly outlined by the Cen n engl j med 371 12 nejm org ters for Disease Control and Prevention CDC A high index of suspicion proper infection control practices and epidemiologic investigations should quickly limit the spread of the virus Recognizing the signs of EVD can be challenging however since early symptoms are nonspecific see box It is essential to obtain a careful and prompt travel
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