America has stopped paying attention, but Ebola is still ravaging Sierra Leone

After the midterm elections, and the calming of the  Ebola nurse debacle, our collective attention turned away from an epidemic that continues to burn in West Africa.

Just because politicians here stopped fighting over travel bans and quarantines doesn't mean the Ebola virus has gone back into hiding among its animal hosts. There may be no new cases in the US. But the war against Ebola continues to rage in West Africa, particularly Sierra Leone. Here's what you need to know about the Ebola epidemic today.

1) Ebola is absolutely out of control in Sierra Leone

Sadly, Sierra Leone has struggled the most to get Ebola under control. According to the New York Times, "The number of new cases in Sierra Leone was above 600 in each of the three weeks leading up to Nov. 25, the most in any three-week period so far." In the capital, Freetown, the number of cases quintupled in the last two months.

Geographical distribution of new Ebola cases as of November 28, 2014. (Via World Health Organization)

Though some parts of the country, including the mountainous Eastern Province, have seen success in tamping out the virus, the WHO's Paul Gully — who is working on the ground in Sierra Leone — says the virus shows no signs of retreat in Western region, particularly the densely-populated capital. The epidemic here is driven by a dire need for more beds to treat positive cases, he said, and more space to isolate suspected cases while they are being tested. The government has said it requires 3,000 beds but right now has less than half of that.

There's also a shortage of personnel. Gino Strada, one of the doctors on the front line of fighting Ebola in Sierra Leone, is opening a hospital to meet the needs of patients with his NGO Emergency. While he has enough gloves and gowns to get started, he is worried about staff.

"The personnel is a critical factor," he said. "To be able to provide each patient with a minimum of five to six hours of medical attention means you have to work on a rotation basis, so you need 100 nurses, and 10 to 15 doctors."

KEY PUBLIC-HEALTH MESSAGES, MEANWHILE, STILL AREN'T GETTING THROUGH IN SIERRA LEONE
Key public-health messages, meanwhile, still aren't getting through. Ebola aid worker Ishmeal Alfred Charles has been going house to house delivering Ebola sanitation information since the summer, when the virus emerged in Sierra Leone. 

"The emphasis on the messages now has changed," he said. "Initially we used to talk about not eating animals like monkeys, bats. Now we know a lot of people are still hiding, trying to bury their loves ones, wash the corpses.

"The key messages we are trying to tell them: you don't have to touch the corpse, don't wash the corpse, keep the corpse in an isolated place."

When someone dies from Ebola, the body has been overtaken by the virus, so the corpse is very infectious. This is why safe burial practices — that don't involve washing and touching corpses — are key to stopping the chains of transmission in this epidemic. But this requires behavioral and cultural changes that are coming very slowly in Sierra Leone, said Charles, particularly since people believe that if they don't properly bury their loved ones, they may be haunted by unsettled spirits.

2) Ebola appears to be coming under control in Liberia and Guinea

There is some good news out of West Africa: this week, the World Health Organization announced that both Liberia and Guinea met a December 1 target for isolating 70 percent of people infected with Ebola and safely burying 70 percent of those who died from the disease. 

The turning point came in October. At a press conference then, one of the World Health Organization's Ebola leads, Bruce Aylward, said the change was the result of public education efforts and the "rapid scale up" in safe burial practices in September.

Ebola chart cases Liberia, (Chart via Science magazine)

Right now, Liberia is experiencing about 20 cases per day, which is far fewer than models projected for the country at this time. Still, the fight — particularly in Liberia — isn't over, as reporter Kai Kupferschmidt writes inScience magazine. In September, clinics needed to be built, patients needed to be isolated, and dead bodies needed to be removed. "Now the country faces new challenges: rebuilding a shattered health care system, tamping down local outbreaks, and looking for ways to drive the number of new cases to zero."

3) There's an unprecedented push to develop new Ebola drugs and vaccines

Even though Ebola has been known for almost 40 years, vaccine and drug development for the disease has been slow at best. Notably, most of the investment in Ebola cures has come from government agencies (such as the US Department of Defense) interested in researching potential biological terrorism weapons.

But the unprecedented nature of this year's Ebola epidemic sparked unprecedented focus on finding an Ebola cure and vaccine, and speeding upthe drug testing and approval process.

There are currently more than a dozen Ebola drugs and three vaccines in development. In September 2014, the drug company GlaxoSmithKline announced it took the extraordinary step of starting mass production on its Ebola vaccine that had just begun being tested in humans. That vaccine justpassed the very first stage of clinical trials, showing that it's safe to use in healthy people. 

Merck also has trials for an Ebola vaccine underway, and Johnson & Johnson will bring its vaccine candidate to testing in the new year. "If one or more of the drugs proves effective and safe, an Ebola vaccine could be ready by as early as next year," according to the New Yorker.

Only a tiny percentage of the drugs and vaccines that enter clinical trials get approved. Whether this Ebola drug development actually turns out to be the silver lining of the worst epidemic in history remains to be seen.

CARD 4 OF 13LAUNCH CARDS

Ebola has never spread to this many countries before

Before 2014, Ebola was a disease that was mostly confined to remote African villages. Health officials didn't worry about it going global.

And then it went global.

THE CURRENT EBOLA EPIDEMIC IS OUTRUNNING OUR ABILITY TO STOP ITEbola first appeared in 1976 during twin outbreaks in Zaire (now Democratic Republic of Congo) and South Sudan, likely spread by bats from nearby jungles. Since then, there have been 20 further outbreaks, but they have usually occurred in isolated rural areas and died out quickly. The countries involved — DRC, Gabon, Sudan — have experience in stamping out the virus before it spreads.

This year has, in many ways, changed people's notions about Ebola — not the biology of the virus but how it can move through populations. In December, the virus is believed to have first turned up in the body of a child in Guéckédou, a rainforest region in southeastern Guinea. That geography was unfortunate: Guéckédou happens to share a very porous border with Sierra Leone and Liberia, where people travel in and out every day to go to the market or conduct business.

By the time the Ebola outbreak was identified in March, it had already spread to all three countries along the border.

And it keeps spreading further: In July, a Liberian-American got on a plane bound for Nigeria, bringing the virus with him and spurring 20 cases and eight deaths in Africa's most populous country. Soon, another case turned up in Senegal. The US faced its first-ever cases and transmissions of Ebola in Dallas and New York City. In Spain, a nurse who had been caring for a repatriated priest got the virus in Madrid. 
Mali confirmed its first Ebola case in October: a two-year-old girl who recently returned from neighboring Guinea who has since died, leading to the discovery of several other cases and deaths. There was also an unrelated outbreak of Ebola in the Democratic Republic of the Congo involving a different type of the virus.

That's nine countries hit with Ebola in one year. There's never been an Ebola outbreak like this before.

THE USUAL METHODS FOR CONTAINING EBOLA, LIKE CONTACT TRACING, DON'T SCALE TO AN EPIDEMIC OF THIS SIZE
By October 2014, Senegal and Nigeria were declared virus-free having stopped their small outbreaks. By November, so was the DRC. But the usual methods for containing Ebola, like contact tracing, haven't scaled to outbreaks the size Liberia, Guinea, and Sierra Leone are battling. 

In the past, public-health officials had a playbook for stopping Ebola. Because the disease isn't very contagious and spreads slowly, they just needed to find all those infected, quarantine them, and identify everyone they'd been in contact with. This could be done in sparsely populated rural areas or places with only a few cases.
But an epidemic is much harder to contain when suddenly many countries are dealing with hundreds and then thousands of cases. Since West Africa had never seen Ebola, the virus had a three-month head start before health officials in the countries involved even realized they were harboring an outbreak. It didn't help that the international community was slow to bring aid to the region, only declaring a public health emergency in August, five months after the first international spread. 

This is why the current Ebola epidemic in Africa is outpacing health agencies' efforts to contain it — and why the number of infected people keeps growing exponentially.