Rashid A. Chotani, MD, MPH Adjunct Professor, GWU

Ebola Viral Disease (EVD) Overview: As of 11 February, 2015  Total Reported Cases = 22,894 [HCW: 848]  Total Reported Deaths = 9,177 [HCW: 495]  Overall CFR= ~40% [~60%]  Case incidence Total weekly case incidence increased for the second consecutive week, with 144 new confirmed cases reported in the week to 8 February Guinea reported a sharp increase in incidence, with 65 new confirmed cases compared with 39 the week before Transmission remains widespread in Sierra Leone, which reported 76 new confirmed cases, while the resurgence in cases in the western district of Port Loko continued for a second week Liberia continues to report a low number of new confirmed cases Source: WHO/CDC/SOS International/ProMed

 Despite improvements in case finding and management, burial practices, and community engagement, the decline in case incidence has stalled. The spike in cases in Guinea and continued widespread transmission in Sierra Leone underline the considerable challenges that must still be overcome to get to zero cases. The infrastructure, systems, and people needed to end the epidemic are now in place; response measures must now be fully implemented.  Increasing geographical spread in Guinea and widespread transmission in Sierra Leone, and a rise in incidence demonstrates that the EVD response still faces significant challenges  As the wet season approaches, there is an urgent need to end the outbreak in as wide an area as possible, especially in remote areas that will become more difficult to access  In light of the recent increase in cases in northern Guinea, cross-border meetings between Guinea, Mali, and Senegal are planned to strengthen coordination of surveillance. A rapid-response team has also arrived in the border area between Lola, Guinea, and Côte d’Ivoire to assess risk and strengthen surveillance  The target is for 100% of new cases to arise among registered contacts, so that each and every chain of transmission can be tracked and terminated In Guinea in the week to 25 January, 14 of 26 (54%) new confirmed and probable cases in arose among registered contacts In Liberia in the 9 days to 31 January, 7 of 7 (100%) new confirmed cases arose among registered contacts and In Sierra Leone in the week to 18 January 26 of 121 (21%) confirmed cases arose among registered contacts Ebola Viral Disease (EVD) Overview: As of 11 February, 2015 Source: WHO/CDC/SOS International/ProMed

Cumulative Cases & Deaths by Week: 05 December 2014 to 11 February, 2015 Senegal declared outbreak free: 17 October Nigeria declared outbreak free: 19 October Spain declared outbreak free: 02 December Mali declared outbreak free: 21 January Mali 8 Cases & 6 Deaths Nigeria 20 Cases & 8 Deaths USA 4 Cases & 1 Death Senegal 1 Case 0 Death Spain 1 Case 0 Death UK/Scotland 1 Case 0 Death These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. Source: WHO/CDC/SOS International

Cumulative Cases & Deaths in HCW by Week: 05 December 2014 to 11 February, 2015 Total Cases 848 Total Deaths 495 Case-Fatality Rate ~ 60% One death in USA was a HCW infected in Guinea Mali 2 Cases & 1 Deaths Nigeria 11 Cases & 5 Deaths USA 3 Cases & 1 Death Spain 1 Case 0 Death UK 1 Case 0 Death * The marked increase from the total of HCW infections reported last week is due to additional cases reported from Sierra Leone that have occurred since the onset of the epidemic. These are not infections that have occurred between the two most recent reporting periods. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. Source: WHO/CDC/SOS International For each country the first three bars represent cases & the subsequent three bars represent deaths NOT New Cases*

Ebola Viral Disease (EVD) Overview: As of 11 February, 2015  People aged 45 and over are almost 4 times more likely to be affected than are children  Phase-3 trials of two candidate Ebola vaccines began at the end of January and early February in Liberia, Sierra Leone and Guinea  It will take about six months for results from the phase-3 trials to be known  The production of vaccines will go on while the trials are underway  Huge stock of millions of doses of vaccine available by mid-year Source: WHO/CDC/SOS International/ProMed Country Cumulative number of confirmed and probable cases by Gender and Age Strata in Guinea, Liberia, and Sierra Leone By Gender* (per 100,000 population) By Age Strata # (per 100,000 population) MaleFemale0-14 years15-44 years45+ years Guinea 1413 (26) 1508 (28) 460 (10) 1648 (35) 791 (51) Liberia 2801 (141) 2746 (140) 943 (55) 2981 (175) 1145 (214) Sierra Leone 5037 (177) 5400 (186) 2201 (91) 5751 (222) 2298 (311) NOTE: Total for Liberia, Sierra Leone, and Guinea where sex is known but age may not be known. Cases per capita are available in the WHO external situation report. Population figures are based on estimates from the United Nations Department of Economic and Social Affairs. *Excludes cases for which data is not available on gender. # Excludes cases for which data on age are not available.

EVD Performance Indicators Source: WHO

EVD Performance Indicators Source: WHO

Funding Issues  Grépin in a recent study using data from the United Nations Office for the Coordination of Humanitarian Affairs’ financial tracking system published in the British Medical Journal found that around 40% (about $1.09 billion of $2.89 billion) of pledges had been received by their intended recipients by the end of Source: WHO/CDC/SOS International/ProMed/BMJ

Impact on: Economics, Global Security & Regional Instability  Economics  A World Bank report published in late January describes severe drops in employment and income in West Africa, and a loss of $1.6 billion in output; over 12% of the combined GDP of Guinea, Sierra Leone, and Liberia  Global Security September 25, 2014 President Barack Obama called Ebola a growing threat to global security Mid-September 2014, the U.N. Security Council convened its first ever health- related emergency meeting Resolution declaring the outbreak “a threat to international peace and security”; the measure garnered 134 co-sponsors, setting a new record October 2014, Dr. Margaret Chan, director general WHO, suggested that the outbreak could lead to outright state failure, a warning the Security Council reiterated in November.  Regional Instability: The challenge is in determining whether war and disease have any sort of causal relationship Other destabilizing forces that often accompany or mirror the devastation of disease; economic shocks, food protests, or natural disasters As the economies of these three nations decimate food insecurity will rise December 2014, the U.N. Food and Agriculture Organization and the World Food Program estimated that half a million people in Guinea, Liberia, and Sierra Leone are food insecure — a number that could rise to one million by March 2015 Ebola-related protests are currently more frequent in Liberia than in Guinea or Sierra Leone, a food protest would likely have a larger impact and engender a greater risk of violence in the comparatively less-democratic Guinea Source: WHO/CDC/SOS International/ProMed/WB/UN

Conclusion  The World is “making this up” as we go and we have to become more comfortable with uncertainty  The current epidemic in West Africa which struggled to meet the basic healthcare needs of populations has made it impossible to managing acute care for Ebola patients  Countries with weak health systems and few basic public health infrastructures in place cannot withstand sudden shocks, whether these come from a changing climate or a runaway virus  Preparedness, including a high level of vigilance for imported cases and a readiness to treat the first confirmed case as a national emergency, made a night-and-day difference. Countries like Nigeria, Senegal and Mali that had good surveillance and laboratory support in place and took swift action were able to defeat the virus before it gained a foothold  No single control intervention is, all by itself, sufficiently powerful to bring an Ebola epidemic of this size and complexity under control. All control measures must work together seamlessly and in unison. If one measure is weak, others will suffer.  Community engagement is the one factor that underlies the success of all other control measures. It is the linchpin for successful control.  Behavioral changes that increase exposure to infected animals needs to be modified  Complex ethical challenges abound related to the use of untested interventions, quarantines, special care, and other issues