Abstract
The variety of factors that contributed to the initial undetected spread of Ebola virus disease in West Africa during 2013-2016 and the difficulty controlling the outbreak once the etiology was identified highlight priorities for disease prevention, detection, and response. These factors include occurrence in a region recovering from civil instability and lacking experience with Ebola response; inadequate surveillance, recognition of suspected cases, and Ebola diagnosis; mobile populations and extensive urban transmission; and the community's insufficient general understanding about the disease. The magnitude of the outbreak was not attributable to a substantial change of the virus. Continued efforts during the outbreak and in preparation for future outbreak response should involve identifying the reservoir, improving in-country detection and response capacity, conducting survivor studies and supporting survivors, engaging in culturally appropriate public education and risk communication, building productive interagency relationships, and continuing support for basic research.
Highlights
The EVD outbreak in Guinea, Liberia, and Sierra Leone was unprecedented in its sheer magnitude and the emergence of EBOV outside the Congo basin
The EVD outbreak was not restricted to the 3 heavily affected West African countries; cases occurred in Senegal, Nigeria, and Mali
EBOV-infected foreign aid workers were transported for treatment to Europe and the United States, and naturally imported cases (United States, Italy, United Kingdom) and domestic transmission (Spain, United States) were reported for the first time in several countries [6]
Summary
Why Here? Why Now? We lack precise answers to these questions. A spillover event is an exceedingly rare but high-consequence event that is likely the most critical initiating factor for an outbreak. Most EBOV outbreaks appear to involve a single initiating spillover event followed by human-to-human transmission [18,19], whereas several MVD outbreaks have been associated with multiple spillover events [4,17] This dissimilarity might reflect a difference in the nature of human interactions with the different primary reservoir species of EBOV and MBGV. Unlike several other African countries, Guinea, Liberia, and Sierra Leone had no past experience in recognizing and managing filovirus outbreaks, and the outbreak occurred in a region with very high endemic levels of malaria that has a similar clinical presentation to EVD These countries had experience with Lassa hemorrhagic fever, that experience most likely negatively affected the initial response: suspecting Lassa might have delayed identifying EBOV and enabled early EBOV transmission. Porous borders and high population mobility within each country and into neighboring countries exacerbated widespread dissemination of disease from urban and rural transmission [27]
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