WHO statement on the meeting of the International Health Regulations Emergency Committee regarding the 2014 Ebola outbreak in West Africa

The first meeting of the Emergency Committee convened by the Director-General under the International Health Regulations (2005) [IHR (2005)] regarding the 2014 Ebola Virus Disease (EVD, or “Ebola”) outbreak in West Africa was held by teleconference on Wednesday, 6 August 2014 from 13:00 to 17:30 and on Thursday, 7 August 2014 from 13:00 to 18:30 Geneva time (CET).

Members and advisors of the Emergency Committee met by teleconference on both days of the meeting1. The following IHR (2005) States Parties participated in the informational session of the meeting on Wednesday, 6 August 2014: Guinea, Liberia, Sierra Leone, and Nigeria.

During the informational session, the WHO Secretariat provided an update on and assessment of the Ebola outbreak in West Africa. The above-referenced States Parties presented on recent developments in their countries, including measures taken to implement rapid control strategies, and existing gaps and challenges in the outbreak response.

After discussion and deliberation on the information provided, the Committee advised that:

• the Ebola outbreak in West Africa constitutes an ‘extraordinary event’ and a public health risk to other States;
• the possible consequences of further international spread are particularly serious in view of the virulence of the virus, the intensive community and health facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries.
• a coordinated international response is deemed essential to stop and reverse the international spread of Ebola.

It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met.

The current EVD outbreak began in Guinea in December 2013. This outbreak now involves transmission in Guinea, Liberia, Nigeria, and Sierra Leone. As of 4 August 2014, countries have reported 1 711 cases (1 070 confirmed, 436 probable, 205 suspect), including 932 deaths. This is currently the largest EVD outbreak ever recorded. In response to the outbreak, a number of unaffected countries have made a range of travel related advice or recommendations.

In light of States Parties’ presentations and subsequent Committee discussions, several challenges were noted for the affected countries:

• their health systems are fragile with significant deficits in human, financial and material resources, resulting in compromised ability to mount an adequate Ebola outbreak control response;
• inexperience in dealing with Ebola outbreaks; misperceptions of the disease, including how the disease is transmitted, are common and continue to be a major challenge in some communities;
• high mobility of populations and several instances of cross-border movement of travellers with infection;
• several generations of transmission have occurred in the three capital cities of Conakry (Guinea); Monrovia (Liberia); and Freetown (Sierra Leone); and
• a high number of infections have been identified among health-care workers, highlighting inadequate infection control practices in many facilities.

The Committee provided the following advice to the Director-General for her consideration to address the Ebola outbreak in accordance with IHR (2005).

States with Ebola transmission

• The Head of State should declare a national emergency; personally address the nation to provide information on the situation, the steps being taken to address the outbreak and the critical role of the community in ensuring its rapid control; provide immediate access to emergency financing to initiate and sustain response operations; and ensure all necessary measures are taken to mobilize and remunerate the necessary health care workforce.
• Health Ministers and other health leaders should assume a prominent leadership role in coordinating and implementing emergency Ebola response measures, a fundamental aspect of which should be to meet regularly with affected communities and to make site visits to treatment centres.
• States should activate their national disaster/emergency management mechanisms and establish an emergency operation centre, under the authority of the Head of State, to coordinate support across all partners, and across the information, security, finance and other relevant sectors, to ensure efficient and effective implementation and monitoring of comprehensive Ebola control measures. These measures must include infection prevention and control (IPC), community awareness, surveillance, accurate laboratory diagnostic testing, contact tracing and monitoring, case management, and communication of timely and accurate information among countries. For all infected and high risks areas, similar mechanisms should be established at the state/province and local levels to ensure close coordination across all levels.
• States should ensure that there is a large-scale and sustained effort to fully engage the community – through local, religious and traditional leaders and healers – so communities play a central role in case identification, contact tracing and risk education; the population should be made fully aware of the benefits of early treatment.
• It is essential that a strong supply pipeline be established to ensure that sufficient medical commodities, especially personal protective equipment (PPE), are available to those who appropriately need them, including health care workers, laboratory technicians, cleaning staff, burial personnel and others that may come in contact with infected persons or contaminated materials.
• In areas of intense transmission (e.g. the cross border area of Sierra Leone, Guinea, Liberia), the provision of quality clinical care, and material and psychosocial support for the affected populations should be used as the primary basis for reducing the movement of people, but extraordinary supplemental measures such as quarantine should be used as considered necessary.
• States should ensure health care workers receive: adequate security measures for their safety and protection; timely payment of salaries and, as appropriate, hazard pay; and appropriate education and training on IPC, including the proper use of PPEs.
• States should ensure that: treatment centres and reliable diagnostic laboratories are situated as closely as possible to areas of transmission; that these facilities have adequate numbers of trained staff, and sufficient equipment and supplies relative to the caseload; that sufficient security is provided to ensure both the safety of staff and to minimize the risk of premature removal of patients from treatment centres; and that staff are regularly reminded and monitored to ensure compliance with IPC.
• States should conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential Ebola infection. The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD. Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation.
• There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD:
  • Confirmed cases should immediately be isolated and treated in an Ebola Treatment Centre with no national or international travel until 2 Ebola-specific diagnostic tests conducted at least 48 hours apart are negative;
  • Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure;
  • Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact.
• States should ensure funerals and burials are conducted by well-trained personnel, with provision made for the presence of the family and cultural practices, and in accordance with national health regulations, to reduce the risk of Ebola infection. The cross-border movement of the human remains of deceased suspect, probable or confirmed EVD cases should be prohibited unless authorized in accordance with recognized international biosafety provisions.
• States should ensure that appropriate medical care is available for the crews and staff of airlines operating in the country, and work with the airlines to facilitate and harmonize communications and management regarding symptomatic passengers under the IHR (2005), mechanisms for contact tracing if required and the use of passenger locator records where appropriate.
• States with EVD transmission should consider postponing mass gatherings until EVD transmission is interrupted.

States with a potential or confirmed Ebola Case, and unaffected States with land borders with affected States

• Unaffected States with land borders adjoining States with Ebola transmission should urgently establish surveillance for clusters of unexplained fever or deaths due to febrile illness; establish access to a qualified diagnostic laboratory for EVD; ensure that health workers are aware of and trained in appropriate IPC procedures; and establish rapid response teams with the capacity to investigate and manage EVD cases and their contacts.
• Any State newly detecting a suspect or confirmed Ebola case or contact, or clusters of unexplained deaths due to febrile illness, should treat this as a health emergency, take immediate steps in the first 24 hours to investigate and stop a potential Ebola outbreak by instituting case management, establishing a definitive diagnosis, and undertaking contact tracing and monitoring.
• If Ebola transmission is confirmed to be occurring in the State, the full recommendations for States with Ebola Transmission should be implemented, on either a national or subnational level, depending on the epidemiologic and risk context.

All States

• There should be no general ban on international travel or trade; restrictions outlined in these recommendations regarding the travel of EVD cases and contacts should be implemented.
• States should provide travelers to Ebola affected and at-risk areas with relevant information on risks, measures to minimize those risks, and advice for managing a potential exposure.
• States should be prepared to detect, investigate, and manage Ebola cases; this should include assured access to a qualified diagnostic laboratory for EVD and, where appropriate, the capacity to manage travelers originating from known Ebola-infected areas who arrive at international airports or major land crossing points with unexplained febrile illness.
• The general public should be provided with accurate and relevant information on the Ebola outbreak and measures to reduce the risk of exposure.
• States should be prepared to facilitate the evacuation and repatriation of nationals (e.g. health workers) who have been exposed to Ebola.

The Committee emphasized the importance of continued support by WHO and other national and international partners towards the effective implementation and monitoring of these recommendations.

Based on this advice, the reports made by affected States Parties and the currently available information, the Director-General accepted the Committee’s assessment and on 8 August 2014 declared the Ebola outbreak in West Africa a Public Health Emergency of International Concern (PHEIC). The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective 8 August 2014. The Director-General thanked the Committee Members and Advisors for their advice and requested their reassessment of this situation within 3 months.