Ebola: Is the Response Justified?

Ebola: is the response justified?

 

Hannah Lewis¹, Aisha Chaudry¹, Gibril Ndow^2,3,&, Mary ME Crossey³, Debbie Garside³, Ramou Njie², Simon D Taylor-Robinson³

 

¹Medical Education Research Unit, Imperial College London, SW7 2AZ, United Kingdom, ²MRC Unit The Gambia, Atlantic Road, Fajara, The Gambia, Gambia, ³Department of Medicine, St Mary’s Hospital campus, Imperial College London, W2 1NY, United Kingdom

 

 

^&Corresponding author
Gibril Ndow, Department of Medicine, 10^th Floor QEQM Wing, St Mary’s Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, United Kingdom

 

 

 

 

The recent Ebola virus disease (EVD) outbreak is the most widely spread and complex EVD outbreak since 1976, affecting ten (10) countries across three continents. It registered a record number of cases and is characterized by a huge variation in levels of infection and case fatality between affected countries. Overall, Liberia, Sierra Leone and Guinea Conakry were the worst affected countries recording more than 27,000 cases in total, including nearly a thousand health workers [1]. These countries have weak health care systems that were ill prepared and poorly equipped to mount an effective response to the outbreak. After more than a year's efforts and millions of dollars in donation to curb the outbreak, new cases continue to be identified in Sierra Leone and Guinea Conakry. In Liberia, where the highest numbers of infection and death were registered earlier during the epidemic, the outbreak was declared over on 9th of May [2]. The WHO commends the continued vigilance of authorities, collective efforts of health workers and communities, and in-pouring donations and help to the successful interruption of transmission in Liberia. However, until the same is achieved in neighboring Guinea and Sierra Leone, there is always a risk of an imported case into Liberia through the porous borders shared with these countries. In this article, we attempt to analyse the various responses to control the epidemic and their respective or collaborative effectiveness or otherwise in interrupting transmission and bringing the outbreak to a halt.

 

 

To describe and explain the various interventions to the outbreak and the collective and respective impact of each on the epidemiological, clinical, economic, social, cultural and, to an extent, political dynamics, we conducted an analytical review of all scientific and media publications related to the EVD epidemic.

 

 

Donations and spending to ease economic impact

 

Having been in a period of peace and economic recovery, Liberia, the Republic of Guinea (Guinea-Conakry) and Sierra Leone have since the onset of the EVD outbreak experienced reversal of development gains. The actual growth for 2014 for the three countries fell short of the projected growth figures from before the EVD epidemic [3] and this pattern continues for 2015 (Table 1). In addition, the total fiscal impact of EVD is more than US$500million in 2014 alone, imposing additional budgetary needs of more than 6.0 percent of GDP in Liberia, more than 3.0 percent in Guinea, and more than 2.5 percent in Sierra Leone [3]. Further costs are estimated for 2015 with the continuing epidemic (Table 1). Public investment cuts have reached more than $160 million over all three countries as a result of the public diverting spending towards tackling the EVD outbreak. This necessary action further hampers the future economic prospects of West Africa [3, 4]. To help quell the epidemic and ease the financial burden, several nations and organizations pledged huge donations [5] and increased spending in West Africa. Projected growth for Liberia increased by 1% in November 2014 compared to that of October [5]. This increase correlates to evidence of the Ebola epidemic abating and economic activity increasing [5, 6]. However, overall donations fell significantly short of the needs to control the outbreak thereby hindering the efforts of local and foreign aid workers [7].

 

Combating the lack of Infrastructure in West Africa

 

Guinea, Liberia and Sierra Leone all have very weak health systems with lack of adequate infrastructure and qualified personnel [8]. Table 2 shows the disproportion ratio of health personnel per 10,000 population in Liberia, Sierra Leone and Guinea Conakry in the years preceding the epidemic. Unsurprisingly, an outbreak of Ebola in densely populated areas in these countries with cases spanning wide geographic dispersions and complicated with public misconceptions, anxiety and fear needed immediate and effective response. However, there were significant failures in response during the early disease outbreak stage when the outbreak was assumed to be "comparable" to previous African outbreaks [9] and traditional containment methods were applied. Owing to lack of beds, more than half the cases of EVD cases in Sierra Leone were not hospitalized [10]. Local staff inefficiencies in dealing with EVD [11], due to the lack of training and experience, resulted in more widespread transmission especially among health care providers [12]. Supplies of personal protective equipment (PPE) often were inadequate, and where available improperly used [12]. Training programs for healthcare personnel working in the epidemic [13], which often included simulation exercises using Ebola survivors [14] have helped control spread and curb the epidemic. A WHO-led Ebola training facility, run by British military personnel, trains 120 health workers a week in Sierra Leone [12]. Confirmed EVD diagnosis requires real time polymerase chain reaction (RT-PCR) in a category 4 laboratory [15] by specially trained staff. The few laboratories in West Africa equipped to do this test were far from the Ebola hot zones and treatment centers. As a result, it can take several days to obtain confirmatory results. To make up for this, mobile diagnostic laboratories were donated and set up close to the Ebola treatment centres [16, 17]. In recent times, the WHO has approved a new ReEBOV Antigen Rapid Test Kit, which will decrease the time to diagnose EVD with acceptable specificity and sensitivity, and overcome many of the challenges associated with laboratory confirmation of EVD in the West African setting [18]. The international community has become more aware of the lack of infrastructure in West Africa and how devastating this can be in disease outbreaks. Developing the healthcare systems in West Africa may become more of a priority and awareness raised during this epidemic may initiate funding for this. However the affected countries have relied greatly on foreign aid. There is a need for more permanent measures, such as building hospitals, training programs, and more reliable and readily available funding schemes which will increase the capacity to quell outbreaks more rapidly and independently as seen in Nigeria and Senegal. Measures to reduce the frequency of zoonotic disease spread, such as regulation of bush meat markets, could also help. It is hoped that consistent aid investments in the health system will help prevent further crises and avert the spending of millions more in emergency aid down the line [19]. The EVD epidemic has made it possible to evaluate the success of different response methods in use. Current methods of preventing transmission, of diagnosing and treating patients, and of communication during outbreaks can all be improved. Lessons learnt from this outbreak and data gathered can be used to improve mathematical models, which can help guide the number and sizes of equipment, staff or treatment units needed as well as make sensible case and cost projections [20]. The UK for International Development and Wellcome Trust created a £6.5million research initiative to fund EVD-related research programs with an aim to better understand the management of Ebola outbreaks [12].

 

Raising awareness in West Africa

 

Having never encountered EVD before, many people in West Africa did not understand why they had to adapt their routine daily practice, while not enough people sought medical care in hospitals. There was an outburst of false rumors and violent attacks [21] as a result of fear and mistrust of foreign aid workers. Potentially contaminated equipment were looted, and sick relatives hidden [22]. A mob attack at an Ebola Treatment clinic in Liberia in August 2014 caused 17 Ebola patients to flee. Good communication to the areas affected is necessary to raise awareness of the dangers of EVD, educate the masses on modes of transmission and the need to limit or change certain practices, and encourage the need to seek treatment quickly. Many communication methods have been used to raise awareness in West Africa, including the Trilogy Emergency Relief Application (TERA) system, which sent out about 2 million mobile phone text messages a month in Sierra Leone [23]. However, it has been argued that the communication caused a great deal of fear, which some believe was unnecessary given that EVD accounts for only a small proportion of deaths in Africa compared to AIDS, diarrheal diseases and respiratory infections [24]. The Liberian president, Mrs. Ellen Johnson Sirleaf, said that the messages provided were "contrary to local tradition and culture" [25]. A justified response may be to invest into appropriate and culturally sensitive mediums of communication. Greater involvement from religious and political authorities in raising awareness of Ebola and combatting fear is crucial, and the WHO identified community participation as a critical success factor for Ebola control [21].

 

Raising awareness globally

 

Public awareness, border screening, healthcare worker training and setting up isolation facilities are all crucial in the identification and early diagnosis of imported EVD cases [26]. EVD has become a dominant headline across all forms of media; with the word "Ebola" being the most commonly used keyword across US, international and African publications between 3^rd August and 8^th August 2014 [27]. Despite only one American death between September 1^st and October 31^st 2014, the word "Ebola" received 10 times more mentions in US online media compared to heart disease which killed more than half a million Americans during the same period [28]. Unfortunately, the mass media response caused a great deal of fear. Tom Frieden, the Director of the Centres for Disease Control and Prevention (CDC) believes that the media coverage may "exaggerate the potential risks" of EVD. Certain aid agencies claimed they were "facing an epidemic of magnitude never seen before" which some felt was fear mongering [25]. Ebola, which has an R0 value of approximately 2, is far less contagious compared to other infectious diseases, such as measles with an R₀ of 17 [20]. Many reason that the exaggerated coverage has led to EVD becoming one of American's top health worries with approximately one in six naming Ebola as the nation's top health concern [29]. Nonetheless, it can be argued that the benefits of public sensitization outweigh the potential harms. Dr Anthony S. Fauci, Director of the US National Institute of Allergy and Infectious Disease, said "the publicity associated with (Ebola) is a good thing even though it may be scaring some people, because it is making people aware" [30].

 

Preventing spread of Ebola

 

Without the current intervention, the CDC estimated that the number of EVD cases in Liberia and Sierra Leone alone could rise to between 550,000 and 1.4 million in 2015 [31]. There have been over 24,282 confirmed, probable and suspected cases and 9,976 reported deaths in Liberia, Guinea and Sierra Leone to March 2015 [32]. In an attempt to prevent global spread, many airlines suspended flights to and from some West African countries [3, 33] despite discouragement from the WHO. Only 35 cases have been reported outside the main transmission zone [32] despite increased global travel nowadays and these cases have been manageable using strict infection control measures [4, 34] in countries with strong health care systems. However, the travel restrictions have negatively affected tourism, import of airfreight, and delivery of essential medical supplies and health experts to the affected areas. Liberia had its incoming flights reduced from 27 per week to just 6 per week [5]. Prevening mass gatherings and closing schools and places of work have been employed to prevent spread locally. Evidence suggests that the number of cases have been lower than predictions in some places. For example, the 20,000 cumulative cases predicted by November 2014 in Nigeria were not reached and therefore the conditions of the epidemic changed due to appropriate response. Furthermore, the incidence rate has seen an increase from 12-17 days doubling time to 15-30 days [10]. However, these control measures may not have been justified methods and may have aggravated fear and economic loss. "The 'tide of fear' triggered by the outbreak could cause 80% to 90% of the economic impact" said Jim Yom Kim, the World Bank President. The fear factor from the Ebola outbreak reduced labor force participation, closed places of employment and disrupted transportation [35]. Local trade has also been affected as EVD survivors are shunned [36]. The WHO estimated that the 2-year regional financial impact range from US$3.8 billion to US$32.6 billion [5]. The outbreak led to the suspension of some non-Ebola aid work [37] and the closure of some hospitals [19] leaving non-EVD patients in need of medical aid helpless [15]. 'Symptoms of racism' triggered out of fear of contact with individuals from West Africa have been reported. A notable case was that of two students from Nigeria denied admission to a Texas college on the basis that the college was no longer accepting applications from countries with confirmed Ebola cases, despite the WHO declaring Nigeria as Ebola free [38]. The WHO failed to act quickly enough to quell the outbreak [11]. The presence of EVD was not confirmed until 3 months after the index case [25] and it took 5 months and 1000 deaths before a public health emergency was declared by WHO [17]. Furthermore, Ebola-like symptoms were documented in Sierra Leone in March 2014, but the official recognition of the spread to Sierra Leone did not arrive until May 2014. It was felt that "modest further intervention efforts" early on could have brought the outbreak under control [25]. The epidemic has not yet finally abated meaning that there is ever more potential for viral evolution as the virus spreads. At least 341 mutations in EVD have occurred since late August and the higher the case count, the more chance for another mutation to occur and the greater possibility of the virus [20]. This could make it more devastating and also render the current candidate vaccines ineffective [39].

 

Treating EVD

 

High CFRs and a great deal of suffering are caused by EVD. The average EVD CFR is around 50% but up to a 90% CFR has been recorded when no treatment is provided [40]. Hydration and supportive therapy are known to lower infection and mortality. It is thought that the therapy allows enough time for the immune system to combat the virus [41]. Despite its effectiveness, many patients may have missed out on treatments such as rehydration therapy, because of the "inaccurate view" that there is no proven Ebola treatment [42]. Furthermore, Dr. Hoolihan of Save the Children said that the process of giving intensive fluids intravenously can only happen "when training and facilities are in place", because the use of needles can put health workers at risk. The accelerated production of experimental drugs and vaccines has proved justified so far. The drug z-Mapp has been shown to reduce the viral load in macaques to an undetectable level after 21 days and has been used successfully at the Royal Free Hospital when treating an EVD patient. Another drug called Favipravir has already been safety tested and is being investigated as a possible treatment [43], as well as others such as brincidofovir and TKM-Ebola [44]. Although no vaccine has been put into use, phase 1 safety trials are underway for cAd3-ZEBOV and rVSV-ZEBOV, the two current candidate vaccines, with promising results [15, 45]. It is hoped that these will improve response to future outbreaks as well as reduce the risk of epidemics.

 

 

It can be concluded that the overall response has been justified despite some failures. Donations have helped relieve some of the financial pressure in West Africa, improvements to the infrastructure and staffing are being made, awareness has been raised and little spread to the rest of the world has been noted. The drugs and vaccines developed could also be justified, but that is not clear yet. Although there has been a great amount of fear caused, which in turn has consequences, and not all methods used have been effective or appropriate, there are lessons to be learnt with reasons to improve response for future disease outbreaks. Importantly, as far as Ebola treatment is concerned, the medical community has learned what is effective in the simple therapeutic compendium, such as aggressive rehydration of patients.

 

 

The authors declare no competing interests.

 

 

The authors have read the final version of this manuscript.

 

 

All authors are grateful to the UK National Institute for Health Research (NIHR) Biomedical Facility and the Medical Education Research Unit at Imperial College London for infrastructure and logistical support. Mary M.E. Crossey is supported by a Fellowship grant from the Sir Halley Stewart Foundation (Cambridge, United Kingdom) and Gibril Ndow from the Wellcome Trust. All authors are participant workers in the European Union Framework 7-funded "PROLIFICA" (Prevention of Liver Fibrosis and Cancer in Africa) project in West Africa, which aims to diagnose, treat and follow-up a cohort of hepatitis B-positive patients in The Gambia, Senegal and Nigeria (EC FP7, P34114; www.prolifica.eu).

 

 

Table 1: world bank projected growth figures before and during the EVD epidemic

Table 2: ratio of health personnel to population in Liberia, Sierra Leone and Guinea Conakry – World Health Statistics 2010

 

 

1. WHO Ebola situation report-27th May 2015; http://apps.who.int/ebola/en/current-situation/ebola-situation-report-27-may-2015. Access 1st June 2015.


2. WHO statement-The Ebola outbreak in Liberia is over; http://www.who.int/mediacentre/news/statements/2015/liberia-ends-ebola/en/; accessed on 1st June 2015


3. The World Bank. Ebola: New World Bank Group Report Shows Growth Shrinking, Economic Impact Worsening in Guinea, Liberia and Sierra Leone. http://www.worldbank.org/en/news/press-release/2014/12/02/ebola-world-bank-report-growth-shrinking-economic-impact-guinea-liberia-sierra-leone. Date Accessed: 10th January 2015.


4. The World Bank. Update on the Economic Impact of the 2014 Ebola http://www.worldbank.org/en/topic/macroeconomics/publication/economic-update-ebola-december. Date accessed: 10th January 2015.


5. The Wall Street Journal. US Agency pledges Nearly $100 Million in Ebola Aid. http://www.wsj.com/articles/u-s-agency-pledges-nearly-100-million-in-ebola-aid-1409862892. Date Accessed: 25/02/2015.


6. Tolbert G. Nyenswah, Matthew Westercamp, Amanda Ashraf Kamali, et al. Evidence for Declining Numbers of Ebola Cases-Montserrado County, Liberia, June- October 2014. Centers for Disease Control and Prevention. 2014; Report number 63. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e1114a2.html. Date accessed: 17th January 2015.


7. Ebola donations lag far behind need. Money CNN. http://money.cnn.com/2014/10/07/pf/ebola-donations/index.html. Date accessed: 23rd March 2015.


8. WHO Press. World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. WHO. 2010. Google Scholar


9. Ebola crisis: WHO accused of "failure" in early response. BBC News Africa. Friday 17 October 2014. http://www.bbc.co.uk/news/world-africa-29668603. Accessed 01/12/2014.


10. Dr Neil Ferguson. Dynamics of the current epidemic: presented at the Special symposium on the Ebola virus. Cockburn lecture theatre, St Marys Hospital. Tuesday 21 October 2014.


11. Maria Cheng. UN: We botched response to the Ebola outbreak. The Big Story. Friday 17 October 2014. http://www.bigstory.ap.org/article/6fd22fbcca0c47318cb178596d57dc7a/un-we-botched-response-ebola-outbreak Accessed: 01/12/2014.


12. Almea Matanock, M. Allison Arwady, Patrick Ayscue, et al. Ebola Virus Disease Cases Among Health Care Workers Not Working in Ebola Treatment Units-Liberia, June-August, 2014. CDC. Report number 63. 2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e1114a3.htm. Accessed: 10th January 2015.


13. Medecins Sans Frontieres. Struggling to Contain the Ebola Epidemic in West Africa. http://www.doctorswithoutborders.org/news-stories/voice-field/struggling-contain-ebola-epidemic-west-africa. Accessed: 01 December 2014.


14. World Health Organization. Liberia: Survivors help train health workers for Ebola care. http://www.who.int/features/2014/liberia-ebola-survivors/en/. Accessed: 20 November 2014.


15. Nicholas J Beeching, Manuel Fenech, Catherine F Houlihan. Ebola virus disease. BMJ. 2014 Dec 10;349:g7348. Google Scholar


16. Sarah Zielinski. Ebola Highlights Problems With Global Health Security. AAAS News. Monday 6 October 2014. http://www.aaas.org/news/ebola-highlights-problems-global-health-security. Date accessed: 20th November 2014.


17. Department for International Development, The Rt Hon Justine Greening MP and Public Health England. New British Ebola labs to help stop spread of virus. https://www.gov.uk/government/news/new-british-ebola-labs-to-help-stop-spread-of-virus. Date accessed: 06th December 2014.


18. World Health Organisation. First Antigen Rapid Test for Ebola through Emergency Assessment and Eligible for Procurement. http://www.who.int/medicines/ebola-treatment/1st_antigen_RT_Ebola/en/ Date accessed: 24/02/2015.


19. Sara Harcourt. The Ebola crisis has proven how important it is to send aid to the countries that need it most. The Independent. 6th October 2014. http://www.independent.co.uk/voices/comment/the-ebola-crisis-has-proven-how-important-it-is-to-send-aid-to-the-countries-that-need-it-most-9778235.html Accessed: 02/12/2014.


20. Gerardo Chowell and Hiroshi Nishiura. Transmission dynamics and control of Ebola Virus Disease; a review. BMC Med. 2014; Volume 12 (1):196. PubMed | Google Scholar


21. Marc Kilstein. Fear in Liberia turns violent as a mob attacks an Ebola clinic. PRI's TheWorld 18th August 2014. http://www.pri.org/stories/2014-08-18/fear-liberia-turns-violent-mob-attacks-ebola-clinic Accessed: 28/11/2014.


22. Tulip Mazumdar. Ebola outbreak: Virus still "running ahead of us", says WHO. BBC News. 10th December 2014. www.bbc.co.uk/news/health-30400304 Accessed: 10/12/2014.


23. Eleanor Klibanoff. The Red Cross is using text messaging to take down Ebola. Health. Weblog. http://www.npr.org/blogs/goatsandsoda/2014/10/27/357647182/the-red-cross-is-using-text-messaging-to-take-down-ebola Accessed: 15/01/2015.


24. Julia Belluz and Steven Hoffman. The Ebola Outbreak's Real Cause: Letting Industry drive the research agenda. http://www.vox.com/2014/8/4/5963751/the-real-cause-of-the-ebola-outbreak-its-not-what-you-think Accessed: 28/11/2014.


25. Chris Smyth. Bungling experts allowed virus to overwhelm Africa. The Times. 31st December 2014. http://www.thetimes.co.uk/tto/health/news/article4310338.ece?shareToken=3db9104a4399d9dc8426d1a6808a9f00 Accessed: 10/01/2015.


26. The Royal Free. High Level Isolation Unit. https://www.royalfree.nhs.uk/services/services-a-z/infectious-diseases/high-level-isolation-unit/ Accessed: 19/01/2015.


27. Amadou Sy, Jessica Pugliese and Amy Copley. The U.S.?Africa Leaders Summit: Major Trends in Media Coverage. http://www.brookings.edu/blogs/africa-in-focus/posts/2014/08/19-us-africa-summit-media-coverage-sy Accessed: 28/11/2014.


28. Media Miser. Ebola mentions in US online media: warranted coverage? http://www.mediamiser.com/infographics/ebola-mentions-us-online-media-warranted-coverage/ Accessed: 28/11/2014.


29. Lydia Saad. Ebola ranks among American's top three health concerns. http://www.gallup.com/poll/179429/ebola-ranks-among-americans-top-three-healthcare-concerns.aspx Accessed: 28/11/2014.


30. Connor Adams Sheets. Fears of Ebola Outbreak Spreading From Guinea Unfounded, Health Officials Say. International Business Times. 3rd April 2014. http://www.ibtimes.com/fears-ebola-outbreak-spreading-guinea-unfounded-health-officials-say-1566750. Accessed: 28/11/2014.


31. Centers for Disease Control and Prevention. Questions and Answers: Estimating the Future Number of Cases in the Ebola Epidemic? Liberia and Sierra Leone, 2014-15. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa-mmwr-estimating-future-cases.html Accessed: 28/11/2014.


32. WHO. Ebola situation report.WHO Report. 8th Feb 2015.


33. International SOS. Travel Restrictions, Flight Operations and screening. https://www.internationalsos.com/ebola/index.cfm?content_id=435 Accessed: 02/12/2014.


34. Dr Poonam Khetrapal Singh. Preparedness is key to our fight against Ebola. http://www.searo.who.int/mediacentre/features/2014/preparedness-is-key-to-our-fight-against-ebola/en/ Accessed: 11/12/2014.


35. Ivana Kottasova. World Bank: Cost of Ebola could top $32 billion. CNN. 9th October 2014. http://edition.cnn.com/2014/09/24/business/ebola-cost-warning/ Accessed: 28/11/2014.


36. Patrick Hettinger. Beyond the Health Crisis, Ebola hits Liberia's Economy hard. Measuring the pulse of Economic Transformation in West Africa. Weblog. http://www.afdb.org/en/blogs/measuring-the-pulse-of-economic-transformation-in-west-africa/post/beyond-the-health-crisis-ebola-hits-liberias-economy-hard-13431/ Accessed: 20/11/2014.


37. Action Aid. Ebola Crisis Appeal. http://www.actionaid.org.uk/ebola Accessed: 01/12/2014.


38. Obinna O Oleribe, Babatunde L Salako, M Mourtalla Ka, et al. Ebola virus disease epidemic in West Africa: Lessons learned and issues arising from W, African countries. Clinical Medicine. 2015; Volume 15(1): 1-4. PubMed | Google Scholar


39. Laurie Garrett. Five myths about Ebola. The Washington Post. Friday 10 October 2014. http://www.washingtonpost.com/opinions/five-myths-about-ebola/2014/10/10/6daf70de-4ffe-11e4-babe-e91da079cb8a_story.html Accessed: 04/12/2014.


40. WHO. Ebola Virus Disease. http://www.who.int/mediacentre/factsheets/fs103/en/ Accessed: 28/11/2014.


41. Professor David Heyman. Ebola: Background and analysis of the current West African outbreak, ebola 2014 and the Media. The Frontline Club, 13 Norfolk Place, London, W2 1QJ. 02/10/14.


42. Smitha Mundasad. Ebola: basic fluid and nutrition care 'being missed'. BBC News. 5 December 2014. http://www.bbc.co.uk/news/health-30347702. Accessed: 06/12/2014.


43. Dr Graham Cooke. Clinical Management in NHS, Vaccination and Treatment: presented at the Special symposium on the Ebola virus. Cockburn lecture theatre, St Marys Hospital. 21 October 2014.


44. Smitha Mundasad. Ebola drug trial starts in Liberia. BBC News. Wednesday 7 January 2015 http://www.bbc.com/news/health-30694998. Accessed: 08/01/2015.


45. GlaxoSmithKline (GSK). Our contribution to the fight against Ebola. http://www.gsk.com/en-gb/our-stories/health-for-all/our-contribution-to-the-fight-against-ebola/ Accessed: 01/12/2014.