The Lancet
Aug 23, 2014 Volume 384 Number 9944 p637 – 713
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Ebola: a failure of international collective action
The Lancet
When a 2-year-old boy in the Guéckédou region of Guinea fell ill on Dec 6, 2013, no one knew that his illness signalled the start of the biggest, most complex outbreak of Ebola the world has ever seen. As of mid-August, 2240 cases and 1229 deaths have been reported from Guinea, Liberia, Nigeria, and Sierra Leone. But WHO believes that these numbers could be a vast underestimation, as the numbers of deaths and infections increase rapidly in Liberia and Sierra Leone. On Aug 8, after a 2 day meeting of the International Health Regulations Emergency Committee, WHO declared the outbreak a “public health emergency of international concern”. This is not because the outbreak has pandemic potential. It does not. If Ebola arrives in high-income and middle-income nations, it should be contained quickly. WHO declared the emergency to escalate the national, regional, and international response to the outbreak’s epicentre in west Africa, recognising that it constituted an “extraordinary event”.

The outbreak continues to be difficult to bring under control. Health workers are dealing with numerous issues they have not had to deal with to this extent when battling Ebola in the past in central and east Africa. These include incredibly weak health systems, with few staff, little equipment, and poor facilities, making disease surveillance, isolation, and supportive care virtually impossible without external assistance. High levels of fear and mistrust about the disease and about health professionals have also led to removal of patients from hospitals and hiding of sick people in communities. Additionally, cross-border movement between the three main affected countries has facilitated spread across a huge expanse. All these factors have made effective contact tracing, which is crucial for containment, extremely difficult, especially in remote, rural areas.

Although WHO is now leading the international response to the crisis, it was initially slow to act at the high level that was needed. Its concern did not match that of the other major player in this outbreak—Médecins Sans Frontières (MSF). On June 24, MSF said that the outbreak was “out of control”, that its teams had reached the limits of what they could do, and it called for a massive deployment of resources to the region. Only on July 31, did WHO launch its joint response plan calling for US$71 million from donors and for the deployment of several hundred more personnel to west Africa. But WHO is not solely to blame for not moving more swiftly. Member states and donors are responsible too. WHO has experienced severe budget cuts over recent years. Its budget for responding to crises and outbreaks fell by 50% from 2012—13 ($469 million) to 2014—15 ($228 million). The crisis shows the importance of sufficient levels of multilateral funding for WHO—the only international agency capable of coordinating the response to a health crisis with global dimensions.

There are other lessons from this outbreak, including the need for increased investment in health system strengthening. Fragile health systems are unable to respond when a sudden, rapidly evolving emergency arises. Communities’ experiences of poorly functioning health facilities might also explain some of their mistrust during this crisis. The World Bank has pledged $200 million to deal with the outbreak and bolster health systems in west Africa, but further investments will be needed from other sources to develop resilient health sectors in the region.

No vaccine or cure exists for Ebola. Interest in developing treatments has been spurred by this outbreak. An experimental vaccine is being fast-tracked into human trials by the US National Institutes of Health. Last week, a WHO-convened ethics committee decided that it was right to use untested drugs in this outbreak. However, as others have commented, a vaccine would probably exist today if Ebola affected a large number of people in high-income countries, making research and development financially attractive to drug companies—a situation that John Ashton, president of the UK Faculty of Public Health, has described as “the moral bankruptcy of capitalism acting in the absence of an ethical and social framework”.

The US Centers for Disease Control and Prevention estimates that the outbreak will last for at least another 3—6 months. On Aug 15, MSF, which has nearly 700 staff on the ground, called the international effort to contain the outbreak “dangerously inadequate”; immediate and massive mobilisation of human and technical resources to the region is still needed not only to deal with the outbreak but also to restore collapsing health systems. The international community must show the collective responsibility and global solidarity absent at the start of this outbreak to bring it to an end. Its failure to do so is allowing a disaster of unprecedented proportions to unfold in west Africa.

Comment
Influenza vaccination in the off-label grey zone
Bruce G Weniger
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In The Lancet, Linda McAllister and colleagues1 report the findings from their influenza vaccination trial conducted in the USA during the 2012–13 season, showing non-inferiority of Stratis, a disposable-syringe jet injector (DSJI) versus needle and syringe for geometric mean titres and seroconversion. As expected for this delivery method, local reactions were more common in patients who received DSJI vaccination, but were generally mild and well tolerated: grade 3 reactions were 6•0% (37 of 616) versus 3•5% (21 of 607) with needle and syringe.
Needle-free jet injection for administration of influenza vaccine: a randomised non-inferiority trial
Linda McAllister, Jonathan Anderson, Kristen Werth, Iksung Cho, Karen Copeland, Nancy Le Cam Bouveret, David Plant, Paul M Mendelman, David K Cobb
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The immune response to influenza vaccine given with the jet injector device was non-inferior to the immune response to influenza vaccine given with needle and syringe. The device had a clinically acceptable safety profile, but was associated with a higher frequency of local injection site reactions than was the use of needle and syringe. The Stratis needle-free jet injector device could be used as an alternative method of administration of Afluria trivalent influenza vaccine.