Ebola: the challenging road to recovery.

The resurgence of polio in Syria in 2013 has shown how a breakdown in public health can lead to the reemergence of previously well-controlled diseases. In 2014 and early 2015 Liberia, Guinea, and Sierra Leone have focused all resources on the Ebola response at the expense of other health programmes. Combined with losing a large proportion of the health-care workforce and the population’s reluctance to attend health-care facilities for fear of Ebola, this means the three countries are now at increased risk of other diseases that their health programmes usually target. As they turn towards health-system recovery, these countries will have to reestablish routine immunisation and other disease control programmes to avoid increases in the incidence of measles and malaria and in the prevalence of tuberculosis or HIV/AIDS. The resources mobilised for Ebola are potentially transferable to infectious disease control programmes and could be used to prevent a surge in communicable diseases. The transfer from response to recovery, as important as it is, cannot however take priority over continued Ebola outbreak control measures until WHO has declared the outbreak over. Several factors increase the risk of communicable disease outbreaks in Ebola-affected countries. The first is decreased vaccination coverage, particularly for measles. In Liberia, during the Ebola outbreak, measles immunisation coverage dropped from 71% to 55%, and measles increased from no reported cases in 2013 to four cases in Lofa County alone, one of the areas hardest hit by Ebola. In Sierra Leone, measles vaccination rates fell from 99% to 76% during the outbreak of Ebola, and the country reported 39 confirmed cases of measles in 2014 compared with 13 cases the year before. Similarly, in Guinea, reported measles cases increased from 59 in 2013 to 215 in 2014. The second factor is the disruption of programmes for tuberculosis, HIV/AIDS, and malaria. Sierra Leone, Guinea, and Liberia have a high incidence of tuberculosis, with about 53 000 new cases each year in the three countries. In 2014, clinical teams and facilities for tuberculosis were repurposed to the Ebola response. Consequently, many new and existing patients could not receive treatment for tuberculosis. There are about 210 000 people with HIV and 50 000 on antiretroviral therapy in the three countries. In Liberia, before the Ebola outbreak, more than 70% of 30 000 patients with HIV had access to treatment. Since the onset of the outbreak, 60% of the 144 HIV/AIDS care centres in the country have closed. The decrease in the proportion of people with HIV on antiretroviral therapy is thought to be due to non-functioning health facilities and patients not attending clinics for fear of contracting Ebola. Similarly, in Sierra Leone 80% of clinics that offer services for pregnant women with HIV are closed, leading to concerns of increased vertical transmission. Ebola has also interfered with malaria control efforts. WHO warned that progress on malaria is at risk in Ebola-affected countries, because the outbreak has halted malaria programmes in some areas. In Liberia, a campaign to distribute bednets was hindered in 2014 because workers were repurposed to Ebola efforts. Malaria programmes have faltered as health workers have moved their focus to Ebola, healthcare facilities have closed, and patients have stayed away for fear of contracting Ebola or fear that the fever from malaria would be mistaken for early symptoms of Ebola. In addition, health workers have suspended simple malaria diagnostic tests due to the fear of spreading Ebola. The third and underlying factor is a shortage of health-care staff—a problem that preceded the Ebola outbreak and has been exacerbated by the tragic death of more than 800 health workers. There were about 100 000 patients per physician in Liberia, 50 000 in Sierra Leone, and 10 000 in Guinea, compared with Published Online February 6, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60203-3