The Lancet
Jun 13, 2015 Volume 385 Number 9985 p2323-2432 e49-e50
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
MERS—the latest threat to global health security
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61088-1
The spread of Middle East respiratory syndrome (MERS) to South Korea, and now to China, is an important signal of the need for increased vigilance in global health security measures. As reported in Correspondence in this week’s issue, the rapid transmission of MERS in South Korea led to 12 laboratory-confirmed cases over a 2-week period in May, and many more cases since, with relatives, medical staff, and a fellow patient all contracting the disease, which started with one 68-year-old man who had travelled to the Middle East.

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Editorial
Iraq’s neglected health and humanitarian crisis
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61089-3
“The situation is bad, really bad, and rapidly getting worse”, said WHO Director-General Margaret Chan in her keynote address to launch a new humanitarian response plan for Iraq last week. Iraq’s health and humanitarian crisis results from decades of war and occupation, most recently the takeover of territory by the Islamic State of Iraq and the Levant (ISIL) and the counter-insurgency launch by the government and its allied forces. Since January, 2014, 2·9 million people have fled their homes and presently 8·2 million people in Iraq require immediate humanitarian support.

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Correspondence
Favipiravir—a prophylactic treatment for Ebola contacts?
Michel Van Herp, Hilde Declerck, Tom Decroo
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61095-9
Since the Ebola outbreak began in March, 2014, 25178 cases of Ebola have been reported.1 To control spread of Ebola in west African communities, vaccination campaigns have been proposed. However, the efficacy of candidate Ebola vaccines for primary prevention has not been proven.2 Furthermore, in communities in which Ebola transmission might be ongoing, an important question is: how will such a vaccination be perceived if a vaccinated person develops Ebola? Such a scenario is possible in people who contract Ebola virus before vaccination. If a person is infected with Ebola virus before vaccination, the vaccine might have a post-exposure prophylactic effect. However, how effective this prophylaxis might be is unknown.2 Moreover, if someone is infected more than 48 h before vaccination, the post-exposure prophylactic effect is likely to be insufficient, leading to possible development of Ebola after vaccination. This scenario is likely to result in serious issues relating to community trust and acceptance of an Ebola vaccine.3 How to exclude Ebola among people presenting with post-vaccination fever is also an issue.2

We make a case for the study of favipiravir (Toyama Chemical, Japan), administered as directly observed therapy for contacts of patients with Ebola. Favipiravir has increased benefit in patients with low Ebola viraemia compared with patients with high viraemia.4 As such, this drug could have a post-exposure prophylactic effect among recently infected contacts and a pre-exposure prophylactic effect among contacts exposed to, but not yet infected by, Ebola virus. Additionally, fever has not been reported as a side-effect of favipiravir (ClinicalTrials.gov, NCT02329054). Furthermore, oral administration of prophylactic favipiravir gives people the choice to interrupt treatment if wanted. Additional effects of prophylactic favipiravir might include increased openness of communities to use alert systems and to support contact tracing services (ie, contacts might be receptive to daily follow-up visits). Finally, to reduce incidence of malaria, prophylactic artesunate-amodiaquine could be administered to the contacts of patients with Ebola. One disadvantage of proposed favipiravir prophylaxis might be the need to exclude pregnant women. To mitigate this problem, pregnancy tests could be included as a routine part of the favipiravir prophylaxis package. Finally, prophylactic favipiravir could be field tested by measurement of incidence of Ebola among contacts of patients with Ebola before and after favipiravir is introduced.

We declare no competing interests.
References
1.WHO. Ebola Situation Report. http://apps.who.int/ebola/current-situation/ebola-situation-report-1-april-2015-0; April 1, 2015. ((accessed April 5, 2015).
2.Regules, JA, Beigel, JH, Paolino, KM et al. A recombinant vesicular stomatitis virus Ebola vaccine—preliminary report. N Engl J Med. 2015; DOI: http://dx.doi.org/10.1056/NEJMoa1414216 (published online April 1.)
3.Onishi, N and Fink, S. Vaccines face same mistrust that fed Ebola. New York Times (New York, USA). March 13, 2015; http://www.nytimes.com/2015/03/14/world/africa/ebola-vaccine-researchers-fight-to-overcome-public-skepticism-in-west-africa.html?_r=0. ((accessed April 5, 2015).)
4.Médecins Sans Frontières. Preliminary results of the JIKI clinical trial to test the efficacy of favipiravir in reducing mortality in individuals infected by Ebola virus in Guinea. http://www.msf.org/article/preliminary-results-jiki-clinical-trial-test-efficacy-favipiravir-reducing-mortality; Feb 24, 2015. ((accessed April 5, 2015).)