Update on the Ebola outbreak - December 2014

Note: this is a limited-depth investigation of the global response to the 2014 Ebola outbreak in West Africa as of December 2014. It’s inevitable that a situation like this one will be difficult to understand and follow. We've relied heavily on reports and official statements from the key responders and news articles. Collecting data in the midst of a crisis is challenging and new information is constantly changing the picture. Furthermore, the people who best understand the situation are extremely busy, and we tried to be careful with how we requested their time. Accordingly, this is not researched and vetted to the same level as our standard recommendations.

Published: December 2014

Our process

From mid-October through mid-December 2014, our investigation has consisted of:

• Reading the WHO’s situation reports, the WHO’s virtual press briefings, the University of Pittsburgh Medical Center’s Health Security Headlines newsletter and
  the CDC’s Morbidity and Mortality Weekly Reports to keep up-to-date with the Ebola response.
• A conversation with Anders Nordström from the UN Office of the Special Envoy on Ebola about the funding gap for the Ebola response plan.
• Conversations with Betty Wolf, the Vice President for Advancement at the CDC Foundation, about the CDC’s funding needs, and Thomas Kurman, the Director of Development at Médecins Sans Frontières (MSF), about MSF’s funding needs.
• Conversations with Dr. Ali Khan, Dean of the University of Nebraska Medical Center, College of Public Health, about funding opportunities in training workshops and innovative approaches to outbreak response, and Dr. Cathy Roth, World Health Organization, about funding opportunities in surveillance systems and vaccine development.
• A conversation with Dr. Oyewale Tomori, Virologist and President of Nigerian Academy of Sciences, about building local capacity for the response.
• E-mail correspondence with Amanda Glassman, the Director of Global Health Policy and a Senior Fellow at the Center for Global Development Center (CGD), and Sneha Raghavan, a Research Assistant at CGD, various journalists and bloggers covering the outbreak, and academics modeling the spread of Ebola.
• Other off-the-record conversations, including with people who have made substantial private gifts to the containment effort.

We have tried to be particularly sensitive to taking the time of people occupied with responding to the outbreak. We don't plan to publish conversation notes from the above conversations, with the exception of the one with Anders Nordström.

See our previous blog post on our investigation of the outbreak here.

Progress on containing the Ebola outbreak

Progress on control efforts, safe burials and case isolation

The WHO Ebola Response Roadmap, published at the end of August, outlined a plan that aimed to stop transmission of Ebola within 6 to 9 months.1 On October 1, the key responders set an aggressive goal of safely burying 70% of the dead and isolating 70% of the cases by December 1.2 It appears that the response effort has largely achieved the safe burial goal and has built a sufficient number of treatment units to achieve the case isolation goal, though it seems now that some of these units aren't ideally located:

• Safe burials. Because of underreporting of deaths and the difficulty of ascertaining the cause of deaths, the WHO does not have a precise estimate of the proportion of the dead safely buried.3 Instead, the WHO examines the number and geographical distribution of trained safe burials teams and reported deaths.4 In a press briefing on December 1, Dr. Bruce Aylward, the WHO Assistant Director-General, Polio and Emergencies, stated that in Liberia, Guinea and Sierra Leone “it’s clear now that more than 70% of the Ebola deaths that we know about are buried safely.”5
• Case isolation. It is also very difficult to estimate the proportion of cases isolated, so the WHO uses the number of beds per case as a proxy.6 Based on this proxy, it seems that, at a national level, Liberia, Sierra Leone and Guinea have met the initial target, but, at a district level, some areas still don’t have sufficient isolation capacity.7 Dr. Aylward stated: “we now believe that two of the three countries, Liberia and Guinea, are currently treating more than 70% of the reported cases. And in Sierra Leone they are probably achieving that in most of the country with the exception being in the western part where they’re currently dealing with real escalating disease.”8 He also acknowledged a “geographic mismatch” between capacity and cases in some areas.9

Changes in case rates

Weekly reported cases have declined in Liberia from mid-November to mid-December.10 Although collecting data in the midst of an outbreak is extremely challenging, this trend seems to reflect an actual decline in transmission rather than an artifact of reporting.11 The WHO situation report on December 10 stated that weekly reported cases are increasing slightly in Guinea, may be increasing or stable in Sierra Leone and are still declining in Liberia.12 The situation appears to be worst in Sierra Leone.13 In general, Dr. Aylward summarized progress on containing the outbreak in a press briefing on December 1 as follows:14

At the end of September, the CDC projected around 114,000 reported cases in Liberia and Sierra Leone (judging from a graph in the paper and uncorrected for underreporting) by December 7 under a scenario of “no additional interventions or changes in behavior” with the vast majority of those cases occurring in Liberia.15

The CDC reported 7,797 cases in Liberia, 2416 cases in Guinea, and 8356 cases in Sierra Leone as of December 14.16 Comparing these to the September projections, reported cases in Liberia have diverged greatly from the non-intervention scenario as the response has ramped up over the past few months. The CDC’s projections and reported cases in Sierra Leone were too low to make a meaningful comparison. The CDC did not publish projections for Guinea.

Despite this progress, the course of the outbreak could change rapidly. For instance, changes in community behavior as cases decline could lead to a resurgence in the outbreak.17

Funding for the Ebola response

In mid-September, the UN Office for the Coordination of Humanitarian Affairs (OCHA), in collaboration with WHO, UN partner agencies and other key responders, released an Overview of Needs and Requirements that requested $987.8 million for stopping the outbreak.18 This document very broadly outlined the planned uses of those funds, which included identifying and tracing people with Ebola, providing support for safe and dignified burials, and establishing treatment centers.19 On November 19, OCHA increased the funding target to $1.5 billion.20

As of December 13, OCHA has tracked about $1.1 billion in contributions and commitments to the response plan, leaving a gap of about $400 million, not counting another $164 million in pledges.21

As of December 9, donor governments had provided an additional $1.2 billion (not counted by OCHA), mostly comprised of in-kind contributions, which support, for example, the construction of treatment centers and the provision of medical supplies.22 Dr. Nordström told us that OCHA’s funding target only covers the needs of UN partner agencies and major NGOs for stopping the outbreak over the six-month period from September 2014 to the end of February 2015 not bilateral support outside of contributions to the UN partner agencies and major NGOs.23 There is currently no estimate of the overall amount required from all actors to stop the outbreak.24

On December 10, Congress also approved $5.48 billion of the $6.18 billion in funding that the Obama administration requested “to contain and end the Ebola outbreak at its source in Africa, enhance domestic preparedness, speed the procurement and testing of vaccines and therapeutics, and accelerate global capability to prevent the spread of future infectious diseases.”25 $2.72 billion will go to the U.S. Health and Human Services Department (primarily the CDC), $2.53 billion will go to the State Department and USAID and $112 million in the Department of Defense.26

We do not have much detail on what donations towards closing the $400 million gap for the UN partner agencies and major NGOs would accomplish. Dr. Aylward characterized the gap in his press briefing on December 1 as follows:27

Dr. Anders Nordström, who works in the Office of the UN Special Envoy for Ebola, mentioned a need for fast and flexible funds to fill in gaps in the larger response effort, for instance, improving management practices, building epidemiological capacity, and coordinating work across organizations and governments.28

We’ve heard in a few private conversations that donations to activities other than stopping the outbreak, for instance contributing to vaccine development, preparing countries bordering the outbreak to handle importations of Ebola cases, or taking advantage of government buy-in to strengthen surveillance systems, may provide the best giving opportunities at this point. We see these as potentially promising areas for philanthropy, but not opportunities that we have to evaluate immediately nor that would warrant diverting donations away from our top charities this year.

The giving opportunity

The CDC’s model published on September 26 projected that by January 20 “without additional interventions or changes in community behavior” Sierra Leone and Liberia would have 550,000 reported cases and, assuming that only 40% of cases are reported, 1.4 million cases in total.29 A more recent study, which we haven't vetted, has estimated that 59% to 85% of cases are reported.30 Using this estimate instead of the original 40%, the CDC would have estimated 935,000 cases by January 20.31 If the Ebola response ended up costing $4.7 billion ($1.5 billion for the UN agency partners and major NGOs, $1.2 billion more from bilateral donors, and another $2 billion approved by the US Congress in December 2014) and saved 467,500 lives (assuming a case fatality rate of 70% and using the higher estimate for cases by January 20), then the cost per life saved would be roughly $7,000.32 This estimate does not include any increase in non-Ebola mortality related to the outbreak due to a disruption in non-Ebola health services nor the substantial economic impacts of the outbreak in West Africa.33 Furthermore, without these interventions, the outbreak likely would have lasted past January and spread to other countries, so we think the cost per life saved may have been substantially lower than this estimate, perhaps meaning that the donations were more cost-effective than our top charities.

On the margin, we do not recommend additional donations to Ebola response instead of our top charities. We doubt the $400 million funding gap for the UN partner agencies and the major NGOs represents more than a small improvement in the odds of containing the outbreak:

• It seems likely that bilateral donors would close a funding gap that increased the odds of containing the outbreak more than a small amount given the risk of international spread, the recognition that stopping the outbreak at its source is the most effective means of preventing importations, and the large contributions made so far by the US government and others.
• Dr. Aylward describes the funding gap now as hindering how long out in time the Ebola response team can plan (e.g. contracts for some employees lasting 2 months instead of 6) or leading to the the use of cheaper, lower-quality equipment (ambulances with a dial-up modem instead of a VSat) rather than as, for example, preventing work in some areas altogether.34
• Substantially more funding could go towards the response over the next few months with significant funding approved by the US government and because it seems that not all bilateral donors have fully disbursed their prior commitments yet.35
• We’ve heard in a few private conversations that other opportunities outside of the core response (for example, general strengthening of routine surveillance, which might be something that people are particularly receptive to due to the outbreak) might be the best use of funds at this point.

Our view is that donors have largely met the need in order to respond to a crisis of extraordinary magnitude. It is possible these efforts have averted millions of deaths (or worse).36 Given the current funding gap and uncertainty around what additional donations would accomplish, we do not recommend that our audience divert their donations away from our top charities. We plan to continue to research other giving opportunities related to the outbreak, such as vaccine development or strengthening surveillance systems, as part of our general work on biosecurity.

Sources

• 1

  “To stop Ebola transmission in affected countries within 6-9 months and prevent international spread.” WHO Ebola Response Roadmap, Pg. 4

• 2
  • ”Following the creation of UNMEER, a comprehensive 90-day plan to control and reverse the epidemic of EVD in West Africa has been put into action. To rapidly reverse the current crisis, capacity will be put in place to isolate at least 70% of EVD cases and safely bury at least 70% of patients who die from EVD by 1 December 2014 (the 60- day target). The ultimate goal is to have capacity in place for the isolation of 100% of EVD cases and the safe burial of 100% of patients who die from EVD by 1 January 2015 (the 90-day target), which is projected to result in a declining rate of transmission.” WHO Situation Report, October 22, 2014, Pg. 7
  • ”Last week at the Bank I said, look, the numbers we need to get behind are 70:70:60; that number is 70% safe burials, 70% cases being managed and cared for properly; and within 60 days of our start date which for UNMEER we're taking as 1st October. So, our goal is to have that in place by 60 days which would be 1st December. And those numbers come from our assessment of what it's going to take to… you've heard Margaret Chan and others talk about bending the curve and trying to get that upward curve go in the other direction in terms of case numbers. And so the 70:70:60 is really designed to strike that balance between how fast, with an incredibly concerted international effort and commitment can we build those capacities and then how fast will that have an impact in terms of cases. And we believe that 70:70:60 that's a real stretch target; that's really pushing the system hard to have that kind of capacity in place but that is the goal because if we don't do it in 60 days and we take 90 days, number one, a lot more people will die that shouldn't and, number two, we will need that much more capacity on the ground eventually to be able to manage the case load.” WHO Virtual Press Briefing, October 14, 2014, Pg. 7

• 3

  ”Estimation of the proportion of EVD deaths that are buried safely is complicated by several factors. First, many of the safe burials that do take place are of people who did not die of EVD. This is explained by the fact that the symptoms of EVD are similar to many other common causes of death in the three intense-transmission countries. The second and most important factor is that deaths have been consistently under-reported during this outbreak and, related to this, some communities are still reticent to adopt safe burial practices that can decrease the risk of viral transmission. As at 23 November, 221 trained safe burial teams were operational: 50 teams in Guinea, 77 teams in Liberia, and 94 teams in Sierra Leone. Both Guinea and Sierra Leone now have more than 80% of planned trained safe burial teams in place, whilst Liberia has 77% of teams in place. However, based on the current number of reported deaths in each country, capacity exists to safely bury far in excess of 100% of reported EVD-related deaths. By contrast with the distribution of capacity to isolate and treat patients, the geographic distribution of safe burial teams is far more even across the three intense-transmission countries, though some more remote areas may still be underserved.” WHO Situation Report, December 3, 2014, Pgs. 8-9

• 4

  “As at 23 November, 221 trained safe burial teams were operational: 50 teams in Guinea, 77 teams in Liberia, and 94 teams in Sierra Leone. Both Guinea and Sierra Leone now have more than 80% of planned trained safe burial teams in place, whilst Liberia has 77% of teams in place. However, based on the current number of reported deaths in each country, capacity exists to safely bury far in excess of 100% of reported EVD-related deaths. By contrast with the distribution of capacity to isolate and treat patients, the geographic distribution of safe burial teams is far more even across the three intense-transmission countries, though some more remote areas may still be underserved.” WHO Situation Report, December 3, 2014, Pg. 9

• 5

  Now, in terms of the numbers and the 70-70 targets, the good news, and there is good news, is in all three countries it’s clear now that more than 70% of the Ebola deaths that we know about are buried safely. This is because in the past 60 days the number of safe burial teams has more than doubled from probably less than 100 or thereabouts to nearly 200 or just over. I think we’re squeaking in at 202 today across the three countries. The obvious question then is that capacity, great, it’s sufficient for the burials and the Ebola deaths that we know about but what about those that we don’t? And working from the number of burials that these teams can do, working from the information we have about possible unreported burials, it’s very clear that there is now enough capacity across these three countries, with the exception of a couple of districts here and there that are low incidence areas, but they certainly have the capacity to manage the full burden of disease and achieve certainly the 70% target and probably substantively higher for burials.” WHO Virtual Press Briefing, December 1, 2014, Pg. 3

• 6

  ”At present, it is difficult to measure directly the proportion of patients who are isolated. Usually, information from clinical investigation forms could be used to provide an accurate estimate, but inconsistencies in the way different clinical investigation teams interpret and define when and how a patient is hospitalized and isolated mean that this information is not reliable enough at present to draw any conclusions about isolation. The most robust method of estimating isolation currently available is to use the capacity to treat and isolate patients by geographical area as a proximate measure of the proportion of EVD cases who are isolated. This can be achieved by dividing the number of available EVD-treatment beds by the number of reported cases over a given period of time in a given location, taking account of varying patterns of health-seeking behaviour (e.g., in areas with poor transport links, cases are unlikely to travel large distances for diagnosis and treatment).” WHO Situation Report, December 3, 2014, Pg. 6

• 7

  “Using this proximate measure of isolation at a national level, all three intense-transmission countries currently have the capacity to isolate all reported cases. In Guinea (table 2) there are 2.3 available beds per reported probable and confirmed EVD case; in Liberia (table 3) there are 11.7 beds for every probable and confirmed case, and in Sierra Leone there are 1.5 beds for every probable and confirmed case (table 4). However, these numbers are, to a degree, an oversimplified representation of a more complex situation within each country. In several areas, such as the districts of Kenema and Kailahun in south Sierra Leone, the low number of new cases means that there is spare isolation and treatment capacity in each district, though patients with EVD can and do seek treatment there from neighbouring districts. Conversely, in western areas of Sierra Leone such as Freetown and Port Loko, treatment and isolation capacity continues to be stretched by a large volume of new patients. Ideally, capacity would be sufficient to treat and isolate a given EVD patient within the patient’s home district. This would have the twin benefits of reducing the time between the onset of symptoms and hospitalization, thus increasing the likelihood of survival, and reducing the distance travelled and time in transit of each patient, thus reducing the risk of further transmission.” WHO Situation Report, December 3, 2014, Pgs. 6-7

• 8

  “In terms of the percentage of cases that we believe are being treated in an Ebola treatment centre or community care centre, we now believe that two of the three countries, Liberia and Guinea, are currently treating more than 70% of the reported cases. And in Sierra Leone they are probably achieving that in most of the country with the exception being in the western part where they’re currently dealing with real escalating disease. It’s one of the particular hotspots of greatest concern. But there is the expectation that they should also be able to meet that 70% target in the coming weeks as planned and additional bed capacity that’s being rolled out comes on line.” WHO Virtual Press Briefing, December 1, 2014, Pg. 3

• 9

  “That said, there is still increasing disease again in a couple of hotspots that are particularly concerning and every one of these countries have hotspots, the biggest area right now of escalating disease that’s of greatest concern is what’s happening in Sierra Leone where amount of new disease is still outstripping bed capacity for the moment, although that should catch up quickly. Also a concern that in Guinea, while there may be enough beds, these are highly concentrated in two areas of the country and we now have twice as many prefectures affected nearly as two months ago. And we know as well that people don’t like to move, so that geographic mismatch is still a concern.” WHO Virtual Press Briefing, December 1, 2014, Pg. 4
  

• 10
  • ”Figure 2: Confirmed Ebola virus disease cases reported each week from Liberia and Monrovia” WHO Situation Report, December 10, 2014, Pg. 4
  • “Case incidence has decreased over the past 4 weeks, with 5 districts (counties) reporting new cases in the 3 days to 3 December. A total of 29 confirmed cases were reported in the 3 days to 3 December. The district of Montserrado, which includes the capital, Monrovia (figure 2), reported 15 confirmed cases, and accounted for more than half of all confirmed cases nationally over the reporting period. Bong (1 confirmed cases), Grand Bassa (7 confirmed cases), Grand Cape Mount (5 confirmed cases), and Sinoe (1 confirmed case) are the only other districts to report a case during the same period. The district of Lofa, in the north of the country and on the border with Guinea and Sierra Leone, reported no cases for the sixth consecutive week." WHO Situation Report, December 10, 2014, Pg. 3

• 11
  • "Again, a couple that asked, so I want to address a few of their questions, whether or not what we're seeing in Liberia is real. And what people are looking at right now is what do the admissions look like in the Ebola treatment centres and, as a number of you know, some of the beds there are freeing up in some parts of the country, in particular. Lofa, we've known about for a couple of weeks. It looks like in Monrovia, itself, they've had a freeing up of some beds there. They also look at the lab data, how many lab confirmed cases, which appears to have plateaued; the number of burials being undertaken, which appears to have declined as well. One of the big concerns is does that mean people are not seeking care because they aren't happy with how people are being treated potentially in facilities or how burials were being conducted, etc? But, again, as they've gone and dug into some of the different data informing that, it suggests that in fact it is real. And then the question becomes, well, why? And, again, remember Liberia has been struggling with disease for some time now, there's been a huge effort to inform the population about the disease, to change the behaviours that put them at risk for the disease and probably, most notably, there was a real step-up on the work to put in place safe burials very, very quickly. It's one of those elements of the response strategy we talked about that is scalable very, very quickly and a couple of different NGOs and others were involved in helping the government do that." WHO Virtual Press Briefing, October 29, 2014, Pg. 4
  • ”We had seen some steep declines in Liberia, as most people are aware, in eastern parts of Sierra Leone and also in parts of Guinea, in important areas such as the capital, Conakry, and in Gueckedou where we were first notified of this so many months ago. That said, there is still increasing disease again in a couple of hotspots that are particularly concerning and every one of these countries have hotspots, the biggest area right now of escalating disease that’s of greatest concern is what’s happening in Sierra Leone where amount of new disease is still outstripping bed capacity for the moment, although that should catch up quickly. Also a concern that in Guinea, while there may be enough beds, these are highly concentrated in two areas of the country and we now have twice as many prefectures affected nearly as two months ago. And we know as well that people don’t like to move, so that geographic mismatch is still a concern.” WHO Virtual Press Briefing, December 1, 2014, Pg. 4
  • ”The decline in the number of Ebola cases in Montserrado County from a peak in mid-September was indicated by three data sources: ETU admissions (73% decline), laboratory results (58% decrease in Ebola-positive test results), and body collection (53% decline). The patterns of change in the three indicators were similar, and there is no apparent common source of systematic error that can account for simultaneous decline in all three indicators. These analyses support accumulating anecdotal evidence that cases in the county were substantially lower in late October than 2 months earlier.” Morbidity and Mortality Weekly Report, November 21, 2014, Pg. 1074
  • "Case incidence has decreased over the past 4 weeks, with 5 districts (counties) reporting new cases in the 3 days to 3 December. A total of 29 confirmed cases were reported in the 3 days to 3 December. The district of Montserrado, which includes the capital, Monrovia (figure 2), reported 15 confirmed cases, and accounted for more than half of all confirmed cases nationally over the reporting period. Bong (1 confirmed cases), Grand Bassa (7 confirmed cases), Grand Cape Mount (5 confirmed cases), and Sinoe (1 confirmed case) are the only other districts to report a case during the same period. The district of Lofa, in the north of the country and on the border with Guinea and Sierra Leone, reported no cases for the sixth consecutive week." WHO Situation Report, December 10, 2014, Pg. 3
  • ”The trends in numbers of newly reported cases, persons admitted to the Foya ETU, and positivity rate among community decedents evaluated for Ebola virus during June 8–November 1, 2014, are consistent with a substantial decrease in transmission of Ebola virus in Lofa County beginning as early as August 17, 2014. The aggregate data from the Lofa County Health Office and case-based data from the Foya ETU describe a peak of reported cases and new admissions respectively in the week ending August 16 followed by a decline in subsequent weeks. The high percentage of positive specimens collected from community decedents during June 8–August 16 suggests that Ebola was causing deaths in communities, whereas the lower percentage during August 24–November 1 suggests that other endemic diseases, such as malaria or typhoid, had become the main causes of mortality as transmission of Ebola virus decreased. The findings from this analysis might indicate the first example in Liberia of a successful strategy to reduce the transmission of Ebola virus in a county with high cumulative incidence.” Morbidity and Mortality Weekly Report, November 21, 2014, Pg. 1068

• 12
  • "Case incidence is slightly increasing in Guinea, decreasing in Liberia, and may be increasing or stable in Sierra Leone." @
  • ”Figure 1: Confirmed Ebola virus disease cases reported each week from Guinea and Conakry” WHO Situation Report, December 10, 2014, Pg. 1
  • ”A total of 103 new confirmed and probable cases were reported nationally during the week to 7 December (figure 1). The national trend in Guinea since early October has been slightly increasing, with between 75 and 148 confirmed cases reported in each of the past 7 weeks, though this picture of relative stability masks important changes in the pattern of EVD transmission within the country. The previously reported surge of new cases in the eastern district of N’Zerekore (4 new confirmed cases in the week to 7 December) appears to have abated, although transmission in the neighbouring district of Macenta (15 new confirmed cases; 15 in the previous week) continues to be intense. There have also been reports of resistance among some communities in Macenta to contact tracing. Several districts in central and northern Guinea have reported persistent transmission, including Faranah (8 confirmed and probable cases), Kankan (4 new confirmed cases; 7 in the previous week), Kerouane (4 new confirmed cases; 0 in the previous week), and Kissidougo (5 new confirmed cases; 1 in the previous week). Persistent transmission in these areas is of particular concern, because the local populations are likely to seek treatment in the north, and in neighbouring Mali in particular, rather than at existing facilities in the south- eastern districts of Gueckedou (2 new confirmed cases in the week to 7 December) and Macenta. The first case imported to Mali travelled from a city in the northern district of Siguiri, which borders Mali, and where there has been persistent transmission since early November (3 new confirmed cases in the week to December; between 1 and 3 confirmed cases for the past 8 weeks). The lack of EVD case-management facilities in this northern, Sahelian zone of the country, combined with a higher than usual degree of resistance among local communities to safe burial practices, make this area vulnerable to an increase in cases. In the west of the country, the capital, Conakry, reported 16 new confirmed cases in the week to 7 December (figure 1). Together with the neighbouring district of Coyah (18 new confirmed cases in the week to 7 December), Conakry has now reported an increase in the number of new confirmed cases during each of the past 3 weeks, while Telimele has reported a case for the first time in over 12 weeks. Although 10 districts are yet to report a case of EVD, there has been a geographical expansion in transmission: as at 1 October, 9 districts had reported a confirmed or probable case during the past 7 days; as at 1 December 14 districts reported a case during the past 7 days).” WHO Situation Report, December 10, 2014, Pgs. 2-3
  • ”Figure 3: Confirmed Ebola virus disease cases reported each week from Sierra Leone and Freetown” WHO Situation Report, December 10, 2014, Pg. 4
  • ”EVD transmission remains intense in Sierra Leone, with 397 new confirmed cases reported in the week to 7 December (3 times as many as Guinea and Liberia combined). The worst affected area remains the capital, Freetown, which reported one-third (133) of all new confirmed cases (figure 3). Transmission remains persistent and intense across the country with the exception of the south, with the districts of Bo (14 cases), Bombali (57 cases), Kambia (10 cases), Kono (24 cases), Koinadugu (2 cases), Moyamba (10 cases), Port Loko (76 cases), Tonkolili (13 cases), and Western Rural Area (57 cases) all reporting high numbers of new confirmed cases. By contrast, the southern districts of Kenema and Kailahun reported 0 cases. Kenema has reported one case since 1 November. Pujehun was the only other district not to report a new case. Bonthe, which had previously not reported a case for the past 2 weeks, reported a single confirmed case in the week to 7 December.” WHO Situation Report, December 10, 2014, Pg. 4

• 13
  • "That said, there is still increasing disease again in a couple of hotspots that are particularly concerning and every one of these countries have hotspots, the biggest area right now of escalating disease that’s of greatest concern is what’s happening in Sierra Leone where amount of new disease is still outstripping bed capacity for the moment, although that should catch up quickly." WHO Virtual Press Briefing, December 1, 2014, Pg. 4
  • "Sierra Leone now has the highest total number of reported cases of the three intense- transmission countries, with 7897 cases reported to date." WHO Situation Report, December 10, 2014, Pg. 1

• 14
  WHO Virtual Press Briefing, December 1, 2014, Pg. 4

• 15
  • We used the program DataThief to extract numbers from the graphs, so we could only get the approximate values of the actual estimates (accurate within 10,000 cases or so).
  • Around 114,000 reported cases in Liberia and Sierra Leone: “FIGURE 2. Estimated number of Ebola cases and daily number of beds in use,* with and without correction for underreporting† — EbolaResponse modeling tool, Liberia and Sierra Leone combined, 2014–2015, Liberia and Sierra Leone combined, 2014–2015”, Meltzer et al. 2014, Pg. 7
  • Vast majority of those cases in Liberia: ”FIGURE 7. Estimated impact of interventions on cumulative number of Ebola cases, with and without corrected data*— EbolaResponse modeling tool, Liberia, 2014”, Meltzer et al. 2014, Pg. 12
  • ”Extrapolating trends to January 20, 2015, without additional interventions or changes in community behavior (e.g., notable reductions in unsafe burial practices), the model also estimates that Liberia and Sierra Leone will have approximately 550,000 Ebola cases (1.4 million when corrected for underreporting) (Appendix [Figure 2]).“ Meltzer et al. 2014, Pg. 3

• 16

  CDC Case Counts, December 14, 2014

• 17

  “And the reason that you have to look into a crystal ball when it comes to Ebola is because you’re dealing with behaviours, you’re dealing with human behaviours and they change. And of all the things that are difficult to predict in this epidemic and this outbreak, the most difficult is human behaviour. In Liberia when I was there just a couple of weeks back, you were already seeing people climbing into taxis again, you were already seeing a little bit of loosening of that hand-washing behaviour, you were seeing some places where they didn’t have the chlorine bucket outside the hotel. So you’re already seeing some of what you were mentioning, Lisa, that complacency slipping in.” WHO Virtual Press Briefing, December 1, 2014, Pg. 11

• 18

  OVERVIEW OF FINANCIAL REQUIREMENTS, Overview of Needs and Requirements, Pg. 11
  

• 19

  OVERVIEW OF FINANCIAL REQUIREMENTS, Overview of Needs and Requirements, Pg. 12

• 20
  • UN OCHA Financial Tracking Service
  • "Funding requested from donors by the UN-coordinated overview of needs and requirements for the Ebola virus disease outbreak increased from US$988 million to US$1.5 billion on 19 November 2014." Global Humanitarian Assistance Crisis Briefing

• 21

  UN OCHA Financial Tracking Service

• 22
  • "International partner governments have provided about an additional $1.2 billion, mostly comprised of in-kind contributions." GiveWell's non-verbatim summary of a conversation with Anders Nordström, December 9, 2014, Pg. 2
  • "1,100 military personnel; 1,700 beds; 140,000 PPE [personal protective equipment] sets; 10,000 test kits; 50,000 community health kits" The ONE Campaign Ebola Response Tracker, United States
  • "The $988 million outlined in September in the United Nation’s (UN) Overview of Needs and Requirements and updated in October to $1.5 billion cover the needs of UN agencies and major non-governmental organizations (NGOs) for the six-month period from September 2014 to March 2015 and assumes significant additional contributions from governments." GiveWell's non-verbatim summary of a conversation with Anders Nordström, December 9, 2014, Pg. 1

• 23
  • "The $988 million outlined in September in the United Nation’s (UN) Overview of Needs and Requirements and updated in October to $1.5 billion cover the needs of UN agencies and major non-governmental organizations (NGOs) for the six-month period from September 2014 to March 2015 and assumes significant additional contributions from governments." GiveWell's non-verbatim summary of a conversation with Anders Nordström, December 9, 2014, Pg. 1
  • "Response Plan for Ebola Virus Outbreak ­ Overview of Needs and Requirements (inter­agency plan for Guinea, Liberia, Sierra Leone, Region) ­ September 2014 ­ February 2015" UN OCHA Financial Tracking Service

• 24

  "There is presently no estimate of the total funds at large needed to contain the Ebola outbreak and associated costs." GiveWell's non-verbatim summary of a conversation with Anders Nordström, December 9, 2014, Pg. 2

• 25
  • ”Congress plans to give the White House $5.48 billion to combat Ebola abroad and at home, meeting most of President Barack Obama’s request as the outbreak burns hot in Sierra Leone.” Bloomberg, Congress Nearly Grants Obama's Ebola Wish List With $5.4B
  • “Today, I ask the Congress to consider the enclosed emergency appropriations request for Fiscal Year (FY) 2015 that includes $6.18 billion to implement a comprehensive strategy to contain and end the Ebola outbreak at its source in Africa, enhance domestic preparedness, speed the procurement and testing of vaccines and therapeutics, and accelerate global capability to prevent the spread of future infectious diseases.” Obama Administration Request for Ebola Funds, Pg. 1

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  “Included in the funding is $2.72 billion for the U.S. Health and Human Services Department, primarily the Centers for Disease Control and Prevention, which is trying to contain the virus in West Africa and also prepare U.S. hospitals for new domestic cases. The State Department and the U.S. Agency for International Development would receive $2.53 billion and the Defense Department $112 million.” Bloomberg, Congress Nearly Grants Obama's Ebola Wish List With $5.4B

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  WHO Virtual Press Briefing, December 1, 2014, Pg. 18

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  "The funding gap of $400 million mostly represents a need for flexible cash contributions that could be quickly spent on things not provided as in-kind contributions. A flexible “trust fund” has raised $130 million so far. More flexible funding could be used to:

  • Improve management practices
  • Build epidemiological capacity
  • Coordinate work across organizations and governments

  Flexible funding could make it possible to better use larger-scale funding. UN agencies and major NGOs had planned to fund some things (e.g. construction of hospital beds) that complement with governments’ in-kind contributions." GiveWell's non-verbatim summary of a conversation with Anders Nordström, December 9, 2014, Pg. 2

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  • “Extrapolating trends to January 20, 2015, without additional interventions or changes in community behavior (e.g., notable reductions in unsafe burial practices), the model also estimates that Liberia and Sierra Leone will have approximately 550,000 Ebola cases (1.4 million when corrected for underreporting) (Appendix [Figure 2]).” Meltzer et al. 2014, Pg. 3
  • " Substantial underreporting of cases might be occurring both in Liberia and Sierra Leone (7). To correct for underreporting, EbolaResponse was used to predict the number of beds in use on August 28, 2014. This number was then compared with the actual number of beds in use (from expert opinion estimates). The difference between the two estimates is the potential underreporting correction factor of 2.5 (Appendix [Table 4])." Meltzer et al. 2014, Pg. 2

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  • "In practical terms, said Jeffrey Townsend, a Yale biostatistician and the study’s lead author, that means that for every 100 known cases, there are 120 actual ones, rather than 250 as in the earlier estimates." New York Times, Fewer Ebola Cases Go Unreported Than Thought, Study Finds
  • "Our analysis of EBOV genome sequences also provided an estimate of the proportion of cases sampled of 58% (20–99%). However, over 70% of confirmed patients for the period of late May to mid June in Sierra Leone were sequenced [8]. The discrepancy suggests that underreporting of cases is approximately 17%, with a maximum of 70%." Scarpino et al 2014, Pg. 15
  • Number of cases = Number of reported cases + Underreporting of cases * Number of reported cases, e.g. 117 (~120) = 100 + 0.17*100.
  • Percent of cases reported = Number of reported cases / Number of cases = Number of reported cases / (Number of reported cases + Underreporting of cases * Number of reported cases), e.g. 85.47% = 550,000 / (550,000 + 0.17 * 550,000) and 58.82% = 550,000 / (550,000 + 0.70 * 550,000)

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  • Number of cases = Number of reported cases * (1 / Percent of cases reported)
  • 643,500 = 550,000 * (1/0.8547)
  • 935,000 = 550,000 * (1/0.5882)

• 32
  In mid-October before the ramp up in the response: "The majority of patients are 15 to 44 years of age (49.9% male), and we estimate that the case fatality rate is 70.8% (95% confidence interval [CI], 69 to 73) among persons with known clinical outcome of infection." WHO Ebola Response Team 2014. As of December 14, reported cases and deaths yielded a case fatality rate of 37%.
  
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  • "The EVD outbreak has disrupted the availability of non-ebola health services, most worryingly the treatment of endemic TB and malaria, and the provision of obstetric care for pregnant women." Overview of Needs and Requirements, Pg. 3
  • "Beyond the terrible toll in human lives and suffering, the Ebola epidemic currently afflicting West Africa is already having a measurable economic impact in terms of forgone output; higher fiscal deficits; rising prices; lower real household incomes and greater poverty. These economic impacts include the costs of healthcare and forgone productivity of those directly affected but, more importantly, they arise from the aversion behavior of others in response to the disease." World Bank, The Economic Impact of the 2014 Ebola Epidemic, Pg. 2

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  “In terms of the funding needs, you know, the big challenge here really has been how long out into the future we can do things. So for example, if we’re hiring people we’re offering contracts for a month or for two months instead of six months....So in terms of the funding needs, right now the main gap is our ability to extend out in time and that compromises the kind of people you can hire, how long you can hire them for and the kind of security you can give them etc...as you go out to many of the districts and counties in particular, what you might find is they have one ambulance instead of two ambulances, they’re using a dial-up modem instead of a VSat. So a lot of things have been done on the cheap, so to speak, and you pay a price for that and the people trying to run the response pay a price for that. They’ve got a 15 watt generator, whatever, that blows every day instead of a proper generator to run their facilities. You just see that sort of threadbare nature of the response as you get out into the districts, just not robust enough, especially for what these people are doing.” WHO Virtual Press Briefing, December 1, 2014, Pg. 18

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  • The ONE Campaign Ebola Response Tracker, United States
  • The ONE Campaign Ebola Response Tracker, United Kingdom

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  "Without a more effective, all-out effort, Ebola could become endemic in West Africa, which could, in turn, become a reservoir for the virus's spread to other parts of Africa and beyond." Farrar and Piot 2014, Pg. 1545