From Epidemic to Endemic: Is Ebola Virus the Next Long-term Global Health Threat?

Naledi Madonsela^* and Sibusiso Khumalo
^*Correspondence: Naledi Madonsela, Department of Public Health, University of Cape Town, Cape Town, South Africa, Email:

Introduction

The Ebola virus disease (EVD) has caused major health crises since its discovery in 1976, with outbreaks primarily in sub-Saharan Africa. While the world has witnessed sporadic and localized outbreaks, the 2014–2016 West African Ebola outbreak, which resulted in over 11,000 deaths, raised alarm about the virus’s potential to cause a global health emergency. Despite advances in diagnostics, treatment, and vaccines, Ebola continues to pose a serious threat to public health due to its high fatality rate, ability to spread in healthcare settings, and the lack of widespread immunity in populations. In the face of this persistent threat, the question arises if could Ebola virus transition from an epidemic to an endemic virus, with consistent outbreaks becoming a regular part of the global health landscape [1].

This article explores the possibility of the Ebola virus becoming endemic, similar to other diseases like malaria or tuberculosis, and the implications this would have for global health systems, surveillance, and vaccine development. The potential for Ebola to evolve into a long-term global health threat requires a closer look at its transmission patterns, the progress in preventive measures, and the challenges posed by local and international health infrastructures. Given the global interconnectedness in the modern era, understanding the dynamics of Ebola transmission and containment is crucial in planning for future preparedness and mitigation strategies.

Description

The biology and transmission of ebola virus

Ebola virus is part of the Filoviridae family, with five known species, four of which cause disease in humans: Zaire, Sudan, Tai Forest, and Bundibugyo. The virus is primarily transmitted to humans from wild animals, including fruit bats, primates, and other wildlife, through direct contact with infected animals or their bodily fluids. Once human-to-human transmission occurs, the virus spreads through bodily fluids such as blood, saliva, and vomit, and has a high fatality rate, often exceeding 50%, though rates can vary significantly depending on the strain and the quality of healthcare available. The typical pattern of Ebola outbreaks is marked by localized incidences, often in rural areas with limited access to healthcare facilities. However, the 2014–2016 West African outbreak demonstrated the virus's potential to spread rapidly within densely populated urban centers, triggering international concerns about its pandemic potential. Since then, efforts have been made to improve outbreak response systems, including the establishment of more robust surveillance, diagnostic protocols, and healthcare infrastructures. While the development of an Ebola vaccine (rVSV-ZEBOV), which has shown efficacy in clinical trials, has been a major step forward, its implementation and the widespread availability of treatments like monoclonal antibodies remain limited. Furthermore, the virus’s ability to persist in certain body fluids for extended periods, even after a person has recovered from infection, raises concerns about continued transmission in the absence of visible symptoms [2].

Challenges in containment and global spread

Despite these advancements, several challenges hinder the complete eradication of the virus. One key challenge is the cultural and social barriers in affected areas, where traditional burial practices involving close contact with deceased bodies have been a significant vector for transmission. Public health campaigns aimed at educating communities and changing these practices have had varying levels of success, often dependent on local trust in healthcare systems and international organizations. Another challenge is the increasing risk of Ebola virus moving beyond traditional geographic boundaries. In today’s interconnected world, individuals can travel across the globe in a matter of hours, presenting a significant risk of spreading the virus to countries where it is not endemic. This was evident during the 2014–2016 outbreak when cases were reported in countries like the United States, Spain, and the United Kingdom, although containment measures quickly controlled these imported cases. Despite this, the risk remains, especially if Ebola becomes endemic in regions with ongoing transmission.

The ongoing occurrence of small outbreaks in countries such as the Democratic Republic of Congo (DRC) raises the possibility that the virus may never be completely eradicated. The DRC, in particular, has experienced multiple outbreaks, and the logistical challenges of responding to these outbreaks in conflict zones and remote areas have led to recurrent episodes of transmission. Even as local health authorities have gained valuable experience in managing Ebola outbreaks, the lack of infrastructure, coupled with political instability, complicates containment efforts [3].

Ebola as an endemic threat

The notion of Ebola transitioning from an epidemic to an endemic virus has gained traction in recent years, especially in regions with frequent outbreaks. The persistence of Ebola in animal reservoirs, particularly fruit bats, means that the virus can remain in the environment, ready to jump to human populations during periods of close interaction. In areas where Ebola outbreaks have been recurrent, such as parts of West and Central Africa, there is concern that the virus may be circulating in a “low-level” endemic state, with sporadic flare-ups of infections that are difficult to track and contain. If Ebola were to become endemic, similar to diseases like malaria or tuberculosis, the implications would be profound. There would need to be ongoing surveillance and rapid response capabilities in place, as well as continuous vaccine distribution and treatment options. Local health systems in endemic areas would have to adapt to the recurrent presence of the virus, implementing strategies to mitigate outbreaks while maintaining public trust in health interventions. Furthermore, global health organizations would need to coordinate with local governments to prevent cross-border transmission and ensure that containment efforts are not hindered by political or logistical challenges [4].

Global preparedness and the role of vaccination

One of the most promising strategies in preventing the spread of Ebola is vaccination. The rVSV-ZEBOV vaccine has shown high efficacy in preventing Ebola infection, and its use has been expanded in outbreak settings. However, there are still significant gaps in vaccine distribution, particularly in remote or conflict-ridden areas where outbreaks are most likely to occur. Additionally, the high cost and the need for proper refrigeration to store vaccines in hot climates pose logistical hurdles. The role of vaccines in preventing Ebola from becoming endemic is clear, but ensuring access to these vaccines for vulnerable populations remains a significant challenge. Public health authorities must prioritize the distribution of vaccines to at-risk populations while also addressing issues related to vaccine hesitancy, which has been observed in some African regions due to mistrust of health authorities.

In addition to vaccines, therapeutic treatments are also evolving. The development of monoclonal antibodies and antiviral drugs has shown promise in treating Ebola infections, and these treatments could further reduce mortality rates if they are made widely available. However, similar to vaccines, access to these treatments is limited by costs and distribution challenges, particularly in low-resource settings [5].

Conclusion

The prospect of the Ebola virus becoming an endemic threat is a complex and concerning one. While major advances have been made in our understanding of the virus, and significant progress has been achieved in vaccine development and therapeutic treatments, Ebola continues to present unique challenges in terms of transmission, containment, and global health infrastructure. Its ability to persist in animal reservoirs, coupled with the social, economic, and political obstacles in affected regions, means that the virus is unlikely to be completely eradicated in the near future. For Ebola to transition from an epidemic to an endemic virus, global health systems must shift their approach from reactive measures to proactive and sustained efforts. This includes enhancing surveillance, improving local healthcare infrastructures, expanding vaccination campaigns, and addressing the underlying social determinants of health that facilitate transmission. The international community must work collaboratively to ensure that health systems in endemic regions are equipped to handle recurrent outbreaks without significant loss of life.

In the long term, Ebola could become another disease that is managed as part of the global public health landscape, like malaria or tuberculosis, requiring ongoing surveillance, treatment, and prevention measures. While it may never be eradicated entirely, the goal should be to minimize its impact and prevent widespread outbreaks from occurring. The lessons learned from previous outbreaks should serve as a foundation for building a comprehensive, resilient global health strategy that includes early detection, rapid response, and equitable access to healthcare solutions.

Acknowledgment

None.

Conflict of Interest

None.

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