It is the war against a virus that we hear precious little about these days. While the majority of the world grapples with the Covid-19 pandemic, another far deadlier disease continues to flare in parts of Africa. And this one really does make Covid seem like the common cold.
The Ebola virus disease (EVD), otherwise known as Ebola hemorrhagic fever (EHF) is the kind of disease that sends fear through the roof. One that is thought to originate in fruit bats and kills on average 50% of those who contract in the most horrifying manner.
This is a savage disease that has been concentrated in Africa since it first appeared in 1976 and is much closer in symptoms and mortality rate to the plague than almost anything we’ve seen in recent centuries. The silver lining and I do use that term loosely, is that it is far less transmissible than most diseases and certainly Covid-19, a fact that has greatly aided the herculean efforts to contain this terrifying virus.
In June 1976, an unknown illness began ravaging Nzara in Sudan, now part of South Sudan. The first known case was that of a storekeeper in a cotton factory, who was hospitalised on 30th June and died a week later. Medical staff present were stumped and it quickly became apparent that this was a new disease, previously unencountered. Between June and December 1976, 284 people contracted the mystery illness and 151 of those died.
A second outbreak occurred almost simultaneously roughly 1,000 km (621 miles) away in the small rural village of Yambuku in Zaire, now the Democratic Republic of the Congo. On 26th August 1976, the school’s headmaster, Mabalo Lokela, began displaying peculiar symptoms. He was said to have recently returned from Northern Zaire close to the border of the Central African Republic, where he spent time close to a river between 12th and 22nd August. And the name of that particular stretch of water was the Ebola River.
Those treating him initially assumed it to be a bad case of malaria and gave him quinine, but with his condition worsening, he was admitted to hospital on 5th September and died just three days later. Quickly others who had been in contact with Lokela fell sick and died shortly after, sending the village into a panic.
The government moved swiftly and placed a quarantine zone around Yambuku, but also the country’s capital Kinshasa. Martial law was imposed while schools and businesses closed as the terrified residents were told to remain at home. A group of doctors set about trying to identify the disease that was rapidly devastating the village of Yambuku and among them was Jean-Jacques Muyembe-Tamfum, who would become the first scientist to come into contact with the disease and survive. And vitally, it was he who took the blood samples from three Belgian nuns who had died at the local hospital that was used by the Centers for Disease Control and Prevention (CDC) to identify this new disease. For his brave work, Muyembe-Tamfum was later described as ‘Africa’s Ebola Hunter’ – and I must say, in terms of catchy titles, this must surely be one of the greatest.
It was soon found that the Belgian nuns at the hospital had inadvertently triggered the spread by giving vitamin injections to pregnant women without sterilizing the syringes and needles. No doubt acts that came with good intentions but had tragic consequences. The outbreak officially lasted just 26 days in which 318 cases were identified and of those 280 people died, meaning this new disease came with an appalling 88% fatality rate.
When the cause was first identified it was thought to be a variant of the Marburg virus, a disease first found in Germany in 1967. It was given the name Ebola, after the river of course, either by Karl Johnson of the American CDC team or Belgian researchers. When scientists began to connect the dots, they initially assumed that the outbreak in Sudan must have been connected, but they were wrong. This wasn’t a single new virus, but two different variants.
The two variants that had emerged at almost exactly the same time were linked, but not through human or animal interaction. There are in fact five variants of the genus Ebolavirus, four of which can cause disease in humans. What appeared in Sudan came to be known as Sudan virus (SUDV), while in Zaire it was first named Zaire Ebola virus, but later changed to simply Ebola virus (EBOV). The other two are the Bundibugyo virus (BDBV), first found in Uganda, and the Taï Forest virus (TAFV), which appeared in the Ivory Coast but has so far only a single recorded human case. The final version is the Reston virus (RESTV), which doesn’t cause illness in humans but does in other primates.
Transmission is primarily through contact with body fluids, such as blood from infected humans or other animals, but also through items, such as clothing, that have recently been contaminated with infected bodily fluids. The incubation period can be anywhere from 2 to 21 days and typically arrives like a shattering flu train with fatigue, fever, weakness, decreased appetite, muscular pain, joint pain, headache, and sore throat among the symptoms.
This is typically followed by nausea, vomiting, diarrhoea, abdominal pain, and sometimes hiccups. From here things go downhill quickly and patients can expect to experience shortness of breath, chest pain, swelling, headaches, confusion and bleeding, both internally and externally.
The lucky ones usually begin their recovery period between seven and 14 days after their first symptoms, while those not so fortunate typically die between six and sixteen days from first symptoms and is often due to shock from fluid loss.
Now, I’ve moved through that fairly briskly but this is a truly frightening disease that often leaves sufferers in hellish pain and the kind of visual scene that many of us will thankfully never have to witness. Considering that many outbreaks occur in rural Africa, often far from major hospitals, the results on tightly knit communities can be nothing short of apocalyptical.
As I said earlier, one of the saving graces of this horror is that it’s far less transmissible than many other diseases. Because of this, both outbreaks in 1976 were successfully stopped and it was nearly twenty years until Ebola reared its ugly head once again.
From 1995 until the present day there have been countless flare-ups, the majority in Central Africa but also in West Africa, that have killed a relatively small number of people. Although it must be said that those small numbers still make up at least 50% of those who become infected and sometimes much more.
In 1995 the focus was again on Zaire with 315 cases and 254 deaths. This was followed by an outbreak in Uganda in 2000 that killed 224 of 425 cases and another in the Democratic Republic of the Congo (DRC) – the country changed its name from Zaire in 1997 – which killed 128 of the 143 recorded cases. This 90% mortality rate is the highest of any Ebola outbreaks to date.
There was no let-up for the DRC when a fever epidemic between April and August 2007 that killed 187 of the 264 cases, many of whom had attended the funeral of a local village chief, was later found to have been Ebola. A few months later in Uganda, the Bundibugyo variant was first discovered as it killed 37 of the 149 recorded cases, and in 2012, two small outbreaks hit the country, the first affected seven people, killing four, and the second affected 24, killing 17.
Also in 2012, there was another outbreak in the DRC affecting 57 people and killing 29, which the WHO believed was caused by tainted bush meat hunted by local villagers around the towns of Isiro and Viadana. What must surely be the unluckiest country in the world was hit again in August 2014 with 66 cases and 49 deaths.
In 2014 the most serious Ebola outbreak so far began in West Africa, which would kill more than all of the others combined. With earlier outbreaks relatively small and well contained, this was a brutal wake-up call. While Ebola had certainly been well known before 2014, the images that began to emerge from West Africa showed just a glimpse of how bad things could get and the extraordinary work that many undertook to halt the virus.
But before we get to the major 2014 outbreak, let’s take a quick look at how medical personnel attempt to contain something as deadly as Ebola.
Considering how much we’re talking about vaccinations these days, that’s probably the best place to start. The good news is there are now two vaccines that were approved in the U.S in 2019 and 2020 after extensive trials in Guinea between 2014 and 2016 and both appear to give full protection around ten days after vaccination. In total, roughly 100,000 people have already been vaccinated against Ebola, but the logistics and remoteness of places like the DRC may make it difficult to commence a full-scale rollout.
And these are just the first vaccines. Another is close behind, while several more are in various stages of development or testing. But the problem isn’t so much about the vaccines, but rather what kind of approach should be used. One strategy appears to be a ‘hotspot’ approach that would target high-risk areas, while another is a ‘ring vaccination’ method that targets those who have been in contact with Ebola and medical workers. This has worked to some degree but some argue it fails to really address the problem and with huge social and political issues in some of the outbreak countries, it’s thought that this approach would be ineffective against a large-scale outbreak.
Ebola education has been a big drive in recent years as many governments attempt to clear up much of the misinformation that came with this virus. A study of Twitter messages after the 2014 outbreak in West Africa, found that roughly 10% of all messages relating to Ebola contained factually inaccurate information.
Simply getting the basics right can immediately save lives. From how to put on personal protective equipment (PPE) to handwashing, from disinfecting surfaces and the temperatures that kill the virus (heating an item for 30 to 60 minutes at 60 °C or boiling for five minutes will do the trick) to how to safely isolate and care for a family member that you think has Ebola.
Burial is another hugely important factor that can often come into direct conflict with cultural traditions. Many burial rituals involve those present being in close contact with the dead body, which you don’t need me to tell you is a big no-no for those who have died of Ebola.
West Africa Outbreak
Up until 2014, all Ebola cases had been concentrated in Central Africa, but this all changed when a small child in Méliandou in Guéckédou Prefecture in Guinea fell sick in December 2013 and died shortly after. According to news reports at the time, the boy’s home was in the vicinity of a large colony of Angolan free-tailed bats which appeared to fit the narrative – though this was never fully confirmed.
The boy’s sister, mother and grandmother died shortly after but tragically, Ebola was not thought to be the cause until much later, and by that point, it was already spreading quickly. In March 2014, the WHO reported that a major outbreak was now underway in Guinea mostly focused on four southeastern districts.
In March 2014, the first cases began appearing in neighbouring Liberia leading to the President shutting the borders in July of the same year. In May 2014, a tribal healer in Sierra Leone who had been treating Ebola patients across the border in Guinea died of the disease and by this point, Ebola was spreading quickly through all three countries.
It was at this point that the world really got a sense of just how destructive Ebola could be. Images of bodies piled up and healthcare workers who looked more like they were going into the damaged reactor at Chernobyl rather than an African village shocked the world.
Liberia was in a terrible situation even before Ebola and the disease pushed the country to the edge. With only 50 fully trained doctors in the country at the time, it was a disaster waiting to happen. By September, the virus had spread to all 15 counties while there were reports of hospitals being abandoned. Schools and universities had long been closed, while areas with high infections were placed into tight quarantines. Towards the end of the year, numbers finally began to fall, thanks in no small part to some heroic work done by contact tracers and those working on the ground to provide safe burial practices.
On 9th May 2015, the country was declared Ebola-free, but two further cases left things pending until 9th June 2015. In total, the epidemic had killed 4,809 in Liberia of the 10,675 recorded cases.
Guinea experienced the most significant social upheaval of the three countries, with riots breaking out in the capital over fears that people were being contaminated by the disinfection process going on in a market. Misinformation was rife and often led to medical teams being attacked, with the Red Cross stating that its teams were attacked on average 10 times each month.
As the disease swept through the country, many rural villages simply shut themselves off, which either worked great if Ebola wasn’t present or completely decimated the village if it was. A study found that nearly two-thirds of Ebola cases in Guinea were believed to be down to burial practices including washing of the body of those who had died. On 25th May 2015, six people were placed in prison isolation when they were found travelling with a corpse that had died of Ebola.
By November, the country had no new cases, but a resurgence, apparently down to an Ebola survivor having sex with several different partners, saw cases rise again. It wasn’t until 1st June 2016 that the country was officially declared Ebola-free. In Guinea 2,543 had died of a recorded 3,811 cases.
In Sierra Leone, food shortages brought on by the aggressive quarantines exasperated the situation further. Several villages were reported as being essentially ‘wiped out’ as the virus tore through the country. On 17th December, President Koroma launched “Operation Western Area Surge” and workers went door-to-door in the capital city looking for possible cases. This led to a surge in new cases but meant that by the following months, numbers began tumbling.
As the country neared total eradication, a few cases persistently popped up, but Sierra Leone was declared free of Ebola on 17th March 2016 after 14,124 cases and 3,956 deaths.
Things weren’t constrained to just these three countries and there were small flare-ups in Nigeria and Mali, while the odd cases appeared in the UK, USA, Spain, Italy and Senegal all from returning aid workers. All of these were treated successfully and made full recoveries.
The West African Ebola epidemic was officially declared over in June 2016 after 28,646 cases and 11,323 deaths. Yet the impact was significantly wider and it’s estimated that the economic damage of the outbreak in what is an already desperately poor area of the world was roughly $50 billion.
A Sleeping Horror
The events in West Africa between 2014 and 2016 had shown the world just how bad Ebola could really be. It kickstarted a much more concise international plan of action should such an outbreak occur again while also significantly speeding up the vaccine process.
But Ebola certainly hasn’t disappeared. The poor DRC had seen no fewer than five small outbreaks in the last five years, while just this year, Guinea and the Ivory Coast both recorded cases and fatalities, though diligent work meant that both outbreaks were quickly brought under control.
We are of course living a hyper-aware time regarding the threat of epidemics and pandemics – though it probably has taken far too long. The rapid spread of Covid-19 showed us just how quickly a virus can envelop the world, but with a fatality rate of only a fraction of that of Ebola, it could have been so much worse. This sleeping horror of a virus is in our world, and a full-scale global outbreak doesn’t even bear thinking of.