Infectious disease: Tough choices to reduce Ebola transmission

is larger than all previous Ebola outbreaks combined, and is still expanding. With a death toll in the thousands, and mortality at around 70%, it has undermined fragile health-care systems by filling hospitals with highly infectious patients and killing health workers. Transmission in dense urban populations presents challenges never before seen. Vaccines and drugs would offer a complementary approach to control and they must be fast tracked. But these medicines are not available for immediate widespread use. To quell this unprecedented outbreak, we have to use methods that have not been tested. Experience from past outbreaks has established reliable methods to control transmission in hospitals and at funerals of people who die from Ebola — two of the three main venues for transmission (see ‘Hospitals and funerals’). These efforts remain essential, and the scientific and operational strands must complement one another. What most distinguishes the current situation from previous outbreaks is the high proportion of transmission occurring in the community. No techniques have been developed to control community transmission at this scale. Notwithstanding uncertainties, the global community must act now. The UK government is leading the international response to Ebola in Sierra Leone, providing technical, financial and logistical help. This article sets out the scientific basis for the UK government’s strategy to assist Sierra Leone’s government to reduce transmission. In addition to substantially scaling up conventional capacities at hospitals, we plan to help to build and support community isolation centres where people can voluntarily come to be isolated if they suspect that they have the disease. These interventions represent uncertain ground, but hesitation is more dangerous than trying out potentially ineffective methods (see ‘Delays mean more deaths’). Climbing rates of infection could soon overwhelm Sierra Leone’s already challenged health services, and so remove any realistic chance of public-health intervention ending the outbreak. The Sierra Leonean health system and the many brave local and international health staff need help to lower transmission to the point at which mopping up remaining islands of high transmission will be possible. Until the outbreak is over, we will not know whether we have launched the best response. We invite critiques and suggestions, but must act swiftly. Further delay will result in more infections and deaths, and only sabotage future efforts.