Key events in the WHO response to the Ebola outbreak
This account of the WHO response gives a timeline and explanation of actions taken, including why the outbreaks were declared an international public health emergency in August 2014.
Chapter 7 - The first report on the Ebola outbreak in Guinea was published on 23 March on the website of WHO’s Regional Office for Africa (AFRO). It described measures taken by the Ministry of Health, together with WHO and other partners, to control the outbreak and prevent further spread. Those measures included multidisciplinary teams deployed to the field to detect and manage cases and trace their contacts. As the report noted, “WHO and other partners are mobilizing and deploying additional experts to provide support to the Ministry.”
WHO immediately mobilized its collaborating laboratory in Lyon, France, together with West African laboratories located in Donka, Guinea, Dakar, Senegal, and Kenema, Sierra Leone, to prepare for the diagnosis of more cases. MSF, which had a well-established presence in the region, rapidly set up isolation facilities.
The first team drawn from institutional partners in the WHO Global Outbreak Alert and Response Network, or GOARN, travelled to Guinea on 28 March. The team was headed by a senior WHO field epidemiologist. As a reporter covering early events in Guinea for Vanity Fair later noted, the international response was “rapid and comprehensive – exactly what you would hope.”
Findings from the investigation were reported on 8 April during a Geneva press conference, where WHO officials alerted reporters to “one of the most challenging Ebola outbreaks that we have ever faced”. The challenges observed included the wide geographical dispersion of cases in both Guinea and Liberia, cases in the capital city, Conakry, and a high level of public fear, anxiety, rumours, and misperceptions.
By mid-April, the cumulative totals in Guinea had risen to 168 cases and 108 deaths in six prefectures. More cases were being reported in Liberia, largely concentrated in Lofa county.
At a meeting jointly convened by the African Union and WHO on 16 April in Angola, WHO Regional Director for Africa, Dr Luis Sambo, summarized the situation as follows: “WHO has issued an alert on the importance of epidemiological surveillance, public information and biosafety measures including strengthening of the quality of support to laboratories. Although the epidemic is still rife, we are hopeful that it will be contained and overcome shortly and that we will be able to mitigate its adverse impact on human lives, travel, economies and international trade.”
Dr Sambo encouraged all health ministers “to strengthen their alert systems and implement the relevant provisions of the International Health Regulations.”
During the third week of April, WHO, in collaboration with GOARN partners, mobilized a new medical team of physicians with expertise in infection prevention and control and in intensive care to support clinicians at Donka Hospital, Guinea’s principal hospital, located in Conakry.
In that same week, Guinea reported 218 clinically compatible cases and 141 deaths. Liberia reported 35 clinically compatible cases. Symptom onset of Liberia’s first confirmed case was retrospectively dated back to 13 March. Sierra Leone was investigating 3 cases that might be either Ebola virus disease or Lassa fever, a disease endemic in large parts of West Africa.
By 5 May, WHO had deployed 112 experts to West Africa to assist in the response, including 68 experts deployed through its global surge mechanism, 10 external experts, and 33 international experts from GOARN partner institutions. Of these, 87 went to Guinea, 20 to Liberia, and 4 to AFRO. Although Sierra Leone had not yet reported a confirmed case, vigilance was high and one expert was sent to support surveillance efforts there.
The expertise among deployed staff had been broadened beyond the traditional areas of epidemiology, laboratory services, infection prevention and control, clinical case management, and logistics to include expertise in medical anthropology, risk communication, and social mobilization. The reason was clear: community resistance had joined inadequate treatment facilities and insufficient human resources as a major barrier to control.
WHO again expressed its heightened level of concern on 6 May, when it convened a high-level meeting in Conakry, attended by governmental health officials and staff from WHO headquarters and AFRO. The purpose of the meeting was twofold: to identify the most important weaknesses standing in the way of a stronger strategic response, and to define the precise support needed from WHO and other partners.
Very encouraging results
On 19 May, Guinea’s Minister of Health briefed the World Health Assembly on the Ebola situation in his country. He referred to field investigations that were “yielding very encouraging results”. As he reported, five of the country’s six foci of intense transmission were coming under control, with Gueckedou remaining the epicentre of transmission.
He credited much of this success to the permanent field presence of more than 70 WHO staff and the rapid deployment by WHO of two mobile laboratories. He also noted the need to combine efforts to control the outbreak with efforts to strengthen the country’s health system.
Later in May, Sierra Leone reported its first 16 cases and 5 deaths, all concentrated in Kailahun district. Within days, that number more than doubled.
By early June, it was clear that large and fluid population movements over exceptionally porous borders were interfering with control measures, most notably contact tracing and monitoring during the 21-day incubation period. To address this problem, WHO introduced a system of cross-border surveillance in the designated “hot zone”, a triangle-shaped forested area where the borders of the three countries converged. Additional epidemiologists were sent to support that effort.
The sense of urgency increased on 23 June, when a second high-level meeting was held in Conakry. Participants included Guinea’s President, a special representative of AFRO’s Regional Director, the head of the WHO country office, the US Ambassador in Guinea, and staff from the US Centers for Disease Control and Prevention (CDC).
A call for WHO leadership
On that same day, a turning point occurred when the GOARN steering committee, which included several MSF staff, held a session to discuss the Ebola situation. Its members expressed a desire for WHO to lead the response more strongly as the only agency with the experience, seasoned senior staff, constitutional mandate, and country presence to do so. A message and report conveying the need for more forceful leadership were sent to Dr Chan on 27 June. She immediately took personal responsibility for the WHO response.
Among her first steps, she declared a level 3 emergency – the highest level –and set in motion plans to hold an urgent high-level ministerial meeting with senior health officials from African countries, partners, Ebola survivors, representatives of airline and mining companies and financial donors, including executives from the African Development Bank.
The broadened range of participants reflected yet another set of problems: the political dimensions of the outbreaks, the impact of restrictions on air travel and trade, fears that companies critically important to national economies might leave, and widespread public perceptions that Ebola virus disease was invariably fatal.
That meeting was held in Ghana from 2 to 3 July and resulted in both significant commitments of financial support and new strategies to accelerate the operational response. Key priorities identified included mobilizing community and religious leaders to improve Ebola awareness and understanding, as well as strengthening surveillance, case finding and contact tracing.
By that time, the areas of intense virus transmission were well known. Participants agreed to deploy additional staff to these areas and to commit additional country funding to the response. The meeting further recommended the establishment of a WHO sub-regional Ebola outbreak coordination centre in Conakry, which became operational on 25 July.
Also in early July, WHO issued the results of an analysis of the situation in the three countries and risk factors for the continuing spread of the disease. The main risk factors amplifying the outbreaks were identified as high-risk cultural practices and traditional beliefs, extensive population movements within countries and across borders, and inadequate coverage with effective containment measures. The magnitude of the task ahead was also recognized: the unprecedented expansion of the outbreaks demanded “enormous and robust response capacity and structures in terms of human capital, financial, operational and logistical requirements.”
Overwhelming demands
Some of these “enormous” needs were addressed in the third week of July, when WHO organized a conference with potential donors of financial and in-kind support. Dr Chan described the overwhelming demands created by the outbreaks and clearly stated that WHO, acting alone, could not meet all response needs for a disease of this scale and complexity.
In reviewing the situation, she noted that all three outbreaks were experiencing a second major wave of transmission, with a third wave of even more intense transmission expected to emerge soon. That wave arrived in September.
On 1 August, Dr Chan attended a meeting in Conakry where the presidents of the three countries had gathered to discuss what they increasingly believed was a public health emergency of unusual severity. In hours of face-to-face discussions with these leaders, she explained why WHO was so deeply concerned and stressed the need for them to take high-level responsibility for the response.
As she argued, WHO could provide technical guidance and scale up its material support but these measures could never substitute for decisive government action. She also spelled out the consequences of allowing the outbreaks to continue, including more bans on travel and trade, isolation from the international community, and severe shocks to their struggling economies.
The meeting resulted in a Joint Declaration of Heads of State and Government of the Mano River Union, which included Cote d’Ivoire as well as the three countries. Commitments set out in the Joint Declaration included the isolation of areas in the cross-border region by police and military forces, with material support provided to citizens in these areas.
The Declaration further recognized the need for international support to build capacity for surveillance, contact tracing, case management, and laboratory services. In parallel, WHO launched an appeal to donors for $100 million needed to support its own plan for stepped up action in the three countries.
The emergency committee meets
On 20 July, an airline passenger from Liberia introduced the virus into Lagos, Nigeria, marking the first time that Ebola entered a new country via international air travel. His Ebola infection was confirmed on 23 July. That event rocked public health communities around the world, leading some to anticipate an “apocalyptic” urban outbreak. It also triggered urgent plans to organize an Emergency Committee to assess the Ebola situation under the provisions in the International Health Regulations. The committee met on 8 August.
The use of emergency committees was introduced in 2005 when the IHR were revised. The committee’s job was to make a recommendation as to whether the event constituted a public health emergency of international concern and what “temporary recommendations” (a special term for official IHR advice) should be issued by Dr Chan to limit further spread of the disease.
The Emergency Committee was chaired by Dr Sam Zaramba, former Director-General of Health Services at Uganda’s Ministry of Health, who played a leading role in responding to that country’s large Ebola outbreak in 2000. He noted several serious challenges confronting the three countries: fragile health systems, lack of experience in dealing with Ebola virus disease, highly mobile populations, and wide-ranging public misperceptions about the disease and its modes of transmission. The experts further assessed the implications for control of active transmission in the three capital cities, the large number of infections and deaths among health care workers, and the likelihood that more cases would be exported.
The Committee reached unanimous agreement that the Ebola outbreaks constituted a public health emergency of international concern and transmitted that decision, together with its temporary recommendations, to the WHO Director-General. WHO declared the outbreaks a public health emergency of international concern on 9 August.
Such declarations, which are rare at WHO, are intended to alert all countries to the likelihood of further international spread. Given West Africa’s mobile populations and porous borders, the outbreaks in Guinea, Liberia, and Sierra Leone behaved like a single epidemiological geography, with little indication of a potential to spread internationally beyond the area. That view changed when the air traveller from Liberia imported the virus into Lagos.
The IHR emergency committee mechanism was set up in 2005 for a second purpose: to ensure that a system of checks and balances was in place to protect against recommended measures, issued solely by the Director-General, that can have severe economic consequences for affected countries, as happened during the SARS outbreak of 2003. The emergency committee on Ebola that met in August recommended exit screening of people travelling from the affected countries, but took a strong position against trade and travel bans, which have no evidence of effectiveness in preventing further international spread. That recommendation was important given the number of travel bans and restrictions in place that were crippling the response and increasing the hardship faced by populations.
The declaration that the Ebola outbreaks constituted a public health emergency of international concern served these purposes, but it was neither the start of the WHO response nor the first warning by WHO to the international community about the severity of the situation, both of which had started months before. As noted previously, the first WHO-deployed GOARN team travelled to Guinea on 28 March. The team’s findings led to stern warnings about the severity of the situation communicated on 8 April. From those early days on, WHO carried the lion’s share of the burden for providing logistical as well as technical support.
The "Roadmap" is issued
On 27 August, WHO launched its “Roadmap” for responding to the epidemic, setting out strategies, categories of risk levels in countries, and time-bound objectives. Since then, the presence of WHO staff in the field has been considerably strengthened, with staff staying to work in areas of high transmission for two to three months to ensure that efforts, also among the many nongovernmental agencies contributing to the response, were coordinated and focused on the most urgent needs.
These staff worked shoulder-to-shoulder with national staff and community leaders in tasks ranging from the treatment of patients to the construction of facilities.
Growing international concern
On 2 September, Dr Chan travelled to Washington, DC and New York City to warn government agencies and health officials that cases were increasing exponentially as the unprecedented scale and complexity of the outbreak continued to escalate.
WHO Assistant Director-General for Global Health Security, Keiji Fukuda, who had just returned from West Africa, warned reporters at a 3 September briefing in Washington that WHO did not have “enough health workers, doctors, nurses, drivers, and contact tracers” to handle the increasing number of cases. As he added, “Most of the infections are happening in the community, and many people are unwilling to identify themselves as ill. And if they do, we don’t have enough ambulances to transport them or beds to treat them yet,” he said.
On 8 September, the US and UK governments announced plans to construct treatment centres in Liberia and Sierra Leone.
On 18 September, an emergency session of the United Nations Security Council was convened to assess the implications of the epidemic as a threat to international peace and security. The event marked the first time that a disease provoked an emergency session of the Security Council.
On that same day, the UN Secretary-General announced the first-ever UN public health mission, with the formation of the UN Mission for Emergency Ebola Response, or UNMEER. The objective was to greatly increase the scale and coordination of the international response and to facilitate its logistics. WHO welcomed the move, especially in view of the heavy logistical burdens that were impeding the response.
UNMEER quickly established an air bridge to facilitate the flow of staff and materials, including badly needed vehicles as well as essential medicines. In some areas, though, demand continued to outstrip supply, especially for kits of personal protective equipment. Even a small treatment centre needed hundreds of these kits per day. Heightened international concern was accompanied by heightened preparedness measures in a large number of countries, especially after cases occurred in the US and Spain. That, too, placed a strain on limited supplies of critically important material support.
UNMEER also devised response plans for each of the three countries, modelled on the WHO Roadmap. Projections of precise needs, such as for treatment beds, foreign medical teams, and burial teams, helped channel the high-level of international concern into equally precise support, especially for the construction of new treatment centres.
However, the staffing of those centres with either national or foreign medical teams lagged behind. Given the unprecedented number of doctors and nurses infected during the outbreaks, many governments were reluctant to send their nationals into such high-risk environments, especially as state-of-the-art treatment for those who fell ill could not be guaranteed. Getting well-maintained vehicles and adequate fuel into remote areas of intense transmission also remained a pressing need.
A year-end commitment
Looking back at WHO’s response, its Director-General said in Washington, DC on 17 December, “We will continue to work with the governments affected by the Ebola outbreak and with development partners in the international community, and international responders to get cases down to zero.”
As she noted, sectors well beyond health had been affected in what had become a humanitarian, social, economic, and security crisis. She issued an urgent call for more field epidemiologists on the ground to undertake aggressive case identification and contact tracing. Above all, she stressed the need for all responders to recognize the importance of community engagement. Without community engagement and cooperation, she noted, technical interventions were doomed to fail.
As the year ended, WHO had already started to work with the three most affected countries to support the rebuilding of resilient health systems based on primary health care. In the view of WHO, such systems needed built-in – not separate – capacity to do disease surveillance, to be able to detect early and respond early to outbreaks caused by any pathogen.
At the same time, countries needed systems designed to provide a suite of essential services, including maternal and child health care, immunizations, the prevention and treatment of endemic infectious diseases, like HIV, TB, and malaria, and management of the rising problem of chronic noncommunicable diseases.
If vulnerable countries were supported in doing both – that is, strengthening primary health care together with essential capacities to detect and respond to health emergencies – they would gain greater social stability and resilience to withstand shocks, also from a changing climate, as well as better health. As she had stated before, “Universal health coverage is one of the most powerful social equalizers among all policy options.”