Bafflement as WHO says DRC Ebola crisis ‘not an international health emergency’

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Controversially, the World Health Organisation has decided that while the Ebola outbreak in the Democratic Republic of Congo – with new cases this week in Uganda – does not meet the criteria for ‘an international health emergency’.

The international body responsible for managing responses to outbreaks of Ebola met last Friday to consider next steps following news that the virus had spread from the Democratic Republic of Congo to Uganda. Natasha Joseph, assistant editor in news and research and science and technology editor at The Conversation writes that it decided that the most recent outbreak was a health emergency, but did not meet all the criteria for declaring it a public health and emergency of international concern. It said that there was still a risk of the infection spreading to neighbouring countries, but that the risk of spreading outside the region remained low. It also commended the ‘heroic’ work of teams working to contain the virus.

Joseph writes that one of the challenges the teams face is ensuring that people who cross borders between countries are screened. But that’s an almost impossible task. There are a lot more informal than formal border crossings.

 

Controversial is what a ScienceMag report called the decision not to call this a Public Health Emergency of International Concern (PHEIC). “It was the view of the committee that the outbreak is a health emergency in the Democratic Republic of Congo and the region, but it does not meet all (the PHEIC) criteria,” Preben Aavitsland, acting chair of an expert committee convened by WHO, said.

The report says the committee gathered for the third time after news emerged this week that the virus had spread from the DRC to neighbouring Uganda, so far killing two people there – a 5-year-old boy and his grandmother – who had crossed the border.

Many infectious disease experts and public officials had expected, and called for, WHO to declare a PHEIC when Ebola broke out of the DRC. “I’m baffled and deeply troubled by this decision,” Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University in Washington, DC, is quoted in the report as saying. “The status quo is no longer tenable. It is time to sound a global alert.”

Gostin and others say declaring a PHEIC would focus global attention on the ongoing health crisis. More than 2400 people have been sickened since the outbreak started in August 2018 – the largest outbreak of Ebola other than when it ravaged West Africa 5 years ago. “If I look back to a similar time in West Africa in 2014, prime ministers and presidents were talking about Ebola,” says infectious disease researcher Jeremy Farrar, who runs the Wellcome Trust in London. “Frankly, that has not happened in this outbreak.”

 

But the WHO did express serious worries about the threat to the DRC and its neighbours and over a lack of funds, says a report from the Centre for Infectious Disease Research and Policy at the University of Minnesota.

The committee said the cluster of cases in Uganda isn’t surprising, and the country’s rapid response underscores the importance of preparedness in neighbouring countries. Though the outbreak is a health emergency in the DRC and the immediate region, it doesn’t meet all three criteria for a PHEIC under the International Health Regulations (IHR). And the experts say that formal temporary recommendations under the IHR would not enhance current response operations.

In a statement, WHO director-general Dr Tedros Adhanom Ghebreyesus, said though the spread of Ebola to Uganda is a new development, it doesn’t signal a shift in outbreak dynamics. “We have the people, the tools, the knowledge, and the determination to end this outbreak,” he said. “We need the sustained political commitment of all parties, so we can safely access and work with communities. We also need the international community to step up its financial commitment to ending the outbreak.”

Aavitsland, senior consultant and infectious disease specialist at the Norwegian Institute of Public Health, said the group concluded that the risk of international spread is still low and that there is nothing to gain by recommending a PHEIC. He added that there was potentially a lot to lose in declaring a PHEIC, such as the risk of airlines stopping flights, border closures, or other restrictive measures that could hurt the DRC’s economy. To declare a PHEIC as a means to raise funds for the outbreak response would be a misuse of the process, health officials said.

Aavitsland said committee members are deeply disappointed that the WHO and its response partners haven’t received enough funding and resources to battle Ebola. Currently, $98m is needed to support the response through July, but so far health officials have received only $43.6m, resulting in a $54m gap.

Dr Mike Ryan, the WHO’s executive director of emergency programmes, said there has been very little funding available to help the DRC’s four closest neighbours prepare for imported Ebola cases – and there’s still a $27m shortfall in that support.

In its recommendations, the emergency committee also tweaked its public health advice, including a recommendation that countries most at risk put approvals in place for investigational medicines and vaccines.

A 3-year-old boy who is one of Uganda’s recently confirmed Ebola cases and three members of his family are back in the DRC where experimental treatments are available, and there are no active cases in Uganda, according to the latest updates from the WHO and Uganda’s health ministry. Four people with suspected infections, however, are still in Uganda and are receiving care at the Bwera Ebola treatment centre, and 98 contacts are being monitored.

Ryan said at the briefing ring vaccination in Uganda is expected to begin tomorrow, now that health officials have a comprehensive list of contacts and contacts of contacts who are eligible to be vaccinated.

Detailing the Ebola events in Uganda, the WHO said health workers at both facilities where Uganda’s first imported case, involving the 5-year-old boy, was treated, had been previously vaccinated. WHO officials added that, since 7 November, Uganda has vaccinated 4,699 healthcare and frontline workers as part of its Ebola preparedness activities and noted that nine Ebola treatment units are in place in districts that border the DRC’s Ituri and North Kivu provinces.

Given the close epidemiologic links of Uganda’s three cases and its high level of preparedness, the WHO said the overall risk to the country is moderate and the risk posed to the region by the new cases in Uganda – with no signs of local transmission at this point – is low.

The DRC Health Ministry has, meanwhile, confirmed 12 more Ebola cases, raising the total to 2,120. Two of the cases are in Biena, an earlier affected area. The others are in Mabalako, Kalunguta, Rwampara, and Mandima. Health officials are still investigating 322 suspected cases.

Nine more people died from their Ebola infections, two in community settings and seven in Ebola treatment centres. The deaths push the outbreak’s fatality count to 1,420.

In its weekly snapshot of Ebola activity in the DRC, the WHO said cases are declining in some hot spots such as Katwa, Beni, and Kalunguta, but continue at a moderate pace in others, such as Mabalako and Butembo. “Recent community dialogue, outreach initiatives, and restoration of access to certain hotspot areas have resulted in some improvements in community acceptance of response activities and case investigation efforts,” the WHO said.

Health officials are still worried about persistent delays in detecting cases and the many Ebola deaths in the community, which raise the risk virus spread. About one third of Ebola patients are dying outside of transit centres or Ebola treatment centres. Also, the WHO said cases continue to rise among health workers, with 118 infected so far.

WHO officials said that Merck, which makes the VSV-EBOV vaccine, recently announced plans to begin producing the vaccine at its facility in West Point, Pennsylvania, in addition to its facility in Germany. Ryan said WHO officials welcomed the new development, which will double vaccine capacity. Currently, the company has 250,000 doses ready to ship and expects to make 100,000 more by the end of the year.

 

More than 2,000 cases of Ebola have been recorded in the Democratic Republic of the Congo (DRC) since last August. Now, despite authorities’ efforts – such as screening millions of travellers moving between the DRC and its neighbours – the disease has spread. The WHO announced on 12 June that a five-year-old boy had died in Uganda after testing positive for Ebola. A day later, his grandmother died. It’s believed he contracted Ebola when they attended the funeral of his grandfather (who died of Ebola) in the DRC. Joseph asked Professor Mosoka Fallah, deputy director general at the National Public Health Institute of Liberia and visiting scientist, Harvard Medical School to explain the implications.

There have now been two Ebola deaths in Uganda. Do we know anything more about these cases?
We now know that a family of 14 travelled from the DRC to Uganda. Most of them crossed at the formal border, but five evaded the main port of entry. Instead they crossed over informally. Those five arrived with symptoms that included diarrhoea and bleeding. This implies a period of illness in the DRC and that they were most likely symptomatic while travelling.
It appears they knowingly evaded the official check point that would have monitored their temperature and physical signs to pick them up as possible Ebola cases.
In some ways this is a replica of the cross-border import and export of Ebola cases between Guinea, Liberia and Sierra Leone that were hit by the 2014 outbreak. Many borders between countries in the region are porous: people are in fact much more likely to cross into a neighbouring country without even going through a formal border crossing.
People cross for all sorts of reasons. One of them is funeral rites. The spread of the cases from Guinea to Liberia and eventually to Sierra Leone centred around funeral rites.

Authorities have worked hard to keep Ebola from spreading beyond the DRC. Does the spread mean they need to do more, or do things differently?
The response teams from both the DRC and Uganda must be commended for preventing the mass cross-border export of Ebola cases given the complex nature of the current outbreak.
There are a lot more informal crossings than the formal ones. The surveillance system for scanning people who are crossing into Uganda are at these formal crossings. This isn’t always foolproof. When I was working in Liberia during the West African epidemic between 2014 and 2016, we found that some people would take antipyretic medications to avoid being detected at the formal border crossings. These drugs bring fevers down so that scanners don’t detect a high temperature.
You may wonder why people would do this. The reality is that people across geographical boundaries don’t have any physical boundaries in their minds. When they are in the DRC and fall ill, they will do what anyone would: seek support from their relatives and friends, some of whom are in border towns.
All of this means that health authorities’ interventions must be strategic. They cannot physically monitor all of the informal porous borders between these countries.
What they need to do now is to mobilise all of the towns and villages that share border points with the regions of DRC that are at high risk for the export of Ebola. These villages and towns can physically monitor their individual crossing points. The local leaders and chiefs can keep a visitor log and identify a common building to keep new visitors from the DRC for observation. These logs should be reported to the regional response team daily.
The visitors can then be tracked back to their village of origin to investigate any linkage to a cluster of cases. Coordinating visitors’ movements across the multiple borders will be the greatest strategic intervention. If possible, mobile application can be deployed to local youths to enter these data for real time reporting and coordination.
This strategy was employed in Liberia during the latter part of the Ebola crisis in the region and was critical in preventing the cross-border import of cases. Even within Liberia some counties – sub-regional division – did this to prevent the import of cases from Monrovia or neighbouring counties. When Lofa county went to zero in November of 2014, it was able to maintain that status by using these methods.

What is being done now to try and ensure the cases in Uganda do not lead to more Ebola infections?
Health workers are tracking the cases, finding out who the five people came in contact with and then taking them to a treatment centre immediately. From the recent situation report from Uganda, they have tracked down 98 contacts which is very impressive. As the average number of contacts per case is 10-12. But they have gone beyond that average.
These are very critical response steps in any epidemic. The surveillance team has to enter the mind of a typical villager from the DRC who knows they’re infected and is trying to escape to relatives in Uganda. They will have to figure out whether the infected people visited traditional healers or local medicine stores. How long were they in Uganda before they were picked up? In this way they’ll be able to identify all the contacts and monitor them.
Ebola is a very difficult disease to contain because of human social and behavioural factors. But it can be easily contained if 100% of the infected people’s contacts are identified and monitored and if cases are quickly removed into treatment units. The sooner you are treated, the higher your chances of surviving Ebola. And the more survivors there are, the more the community will trust response workers.

 

A Congolese woman has become the second patient in Uganda to die of Ebola since the virus crossed the border from the DRC and two other people remain in intensive care, a DRC Health Ministry official is quoted in The Times as saying. The 50-year-old woman was the grandmother of a 5-year-old boy who died earlier after crossing into Uganda with his family from Congo, the ministry said. “The grandmother also died last night,” the official, Emmanuel Ainebyona.

Ainebyona said the two other patients being kept in isolation were the 3-year-old brother of the dead boy and a 23-year-old Ugandan man who displayed Ebola symptoms. Test results for the 23-year-old are expected, he said, adding that a total of 27 contacts are now being monitored.

The report quotes Ainebuyona as saying that Uganda has banned public gatherings in the Kasese district where the patients are being treated.

The current Ebola epidemic began in August last year in eastern Congo and has already infected at least 2,062 people, killing 1,390 of them. The infections in Uganda confirmed that the deadly outbreak has spread for the first time beyond the DRC.

The report says Uganda, which has been on high alert for a possible spread of Ebola and has already vaccinated many frontline health workers, is relatively well prepared to contain the virus. The WHO is bringing in 3,500 additional vaccines and will begin vaccinating more people on Friday.

The report says authorities have struggled to contain the disease partly because health workers have been repeatedly attacked in conflict-ravaged eastern Congo, the epicentre of the outbreak.

 

Kenya remains free from Ebola as test results show that a sick woman does not have the deadly haemorrhagic fever, reports ABC News. Kenya’s Health Minister Sicily Kariuki has announced that a patient isolated at the Kericho County Referral Hospital does not have Ebola. “The results of tests carried out by the Kenya Medical Research Institute laboratories on the 36-year-old lady currently admitted in the isolation unit of the Kericho County Referral hospital have been confirmed to be negative for the Ebola virus disease and other haemorrhagic fevers,” Kariuki said.

The report says the woman showed some symptoms of Ebola after travelling from Malaba on the Kenya-Uganda border, sparking fears that Congo’s current outbreak had spread to Kenya. The outbreak in eastern Congo has killed more than 1,400 people since August and last week it spread to neighbouring Uganda where two people died.

Kenya’s health minister had earlier given assurances that all appropriate measures had been taken to prevent the spread of Ebola. “Precautionary measures have been put in place including isolation of the patient,” said Kariuki, while touring the Nairobi international airport to see how arriving passengers are screened for symptoms of fever.

The report quotes Tedros Adhanom Ghebreyesus as saying that he accepted the decision. “From our side, I would like to pledge that we will continue mobilising global and regional support to control this outbreak as soon as possible. It is not clean until the outbreak in (Congo) is finished,” he said, according to a statement from Uganda’s health ministry.

The spread of Ebola in eastern Congo has been “very unpredictable, with up and down trends,” he said.

In eastern Congo, health officials have begun offering vaccinations to all residents in the hotspot of Mabalako whereas previous efforts had only targeted known contacts or those considered to be at high risk.

 

Specialists in global public health say, meanwhile, that the persistence of Congo’s Ebola outbreak and its deadly spread to Uganda in recent days show how societal issues are as crucial as scientific advances in controlling disease outbreaks. Reuters Health reports that medical scientists, prompted by a devastating West African Ebola epidemic between 2013 and 2016, have worked fast to develop cutting edge vaccines, treatments and antibody-based therapies they hoped would prevent or halt future outbreaks of the virus. That includes an Ebola vaccine developed by Merck & Co Inc that proved more than 95% effective in clinical trials.

But the current Ebola outbreak has continued to spread relentlessly since it began in August 2018 in DRC’s North Kivu province. It has infected more than 2,000 people, killing at least 1,400 of them. And, in recent days, the report says, it reached Uganda, where several cases have been recorded, all in people who had come across the border from Congo.

Public health experts say this underscores the importance of factors beyond medicine – such as trust in authority, engagement and accurate information – in successfully controlling outbreaks of infectious diseases. “Even in the presence of sensitive rapid testing, drugs and a vaccine, this Ebola outbreak has continued to burn on,” Ian Mackay, a virologist and associate professor at the University of Queensland in Australia is quoted in the report as saying. “The core drivers are all key human issues of trust, habits, fears and beliefs. That is the mix that now underpins the spread of any disease.”

Those seeking ways to end the Congo Ebola outbreak’s longevity and persistence say the issues it raises go to the heart of what public health means in the 21st century for countries across the world, rich and poor. The report says the WHO cites mistrust of authorities in Congo, with attacks on healthcare workers and patients avoiding treatment centres, as major factor in the failure so far to contain the Ebola outbreak. Similarly, it cites anti-vaccine misinformation campaigns in the US, Ukraine and elsewhere as allowing measles to spread furiously among people who are fearful and confused.

Jeremy Farrar, director of the Wellcome Trust medical charity and a specialist in global health, draws parallels between the challenge of containing Ebola in Congo and issues elsewhere, such as the surge of cholera in Yemen and the spread of measles in Ukraine, the US and the Philippines. The barriers are more social than scientific, he says. “No public health can work without the support of the society it’s in. The science is clear in all of these things, but unless it has not just tacit support, but engaged support, then public health really struggles,” Farrar is quoted in the report as saying.

A key factor has been greater international travel, and the increased information sharing that comes with it. That is “a double-edged sword”, says Daniel Bausch, director of the UK public health rapid support team and an expert on the Ebola virus.

While improved communication flows can help public health authorities track diseases and spread messages to people about how to protect themselves, greater access to a vast range of information can make the public become more sceptical of authority and can spread misinformation, including about vaccines, Bausch said in the report. “There is so much information flowing, it gets very difficult to pick out the truth. This is not unique to Ebola or Africa – it’s a global problem,” Bausch said.

Emmanuel André, a doctor and professor at Leuven University in Belgium who has been working with people in Congo affected by tuberculosis – another infectious disease – says the way to counter distrust is to engage with people directly affected by a disease or who have direct experience of a medicine to harness their experience. “Medicine and public health have not yet learned how to deal with humility and mistakes,” he said. “How can we ask trust from the people in the North Kivu when political authorities, United Nations agencies and international NGOs have jointly failed to provide primary services – including health? How can we ask them to expect that these same actors now would be able to provide a solution?”

The report says a study André conducted in Congo in 2014-2016 found in the detection of tuberculosis – disease that can spread widely if people with it don’t come forward for treatment – training volunteer screeners from local communities, mainly people who had themselves been treated for TB or had a family history of the disease, improved diagnosis rates and engagement. “Building trust with the people is critical,” he said.

The Conversation report
World Health Organisation statement
ScienceMag report
CIDRAP report
The Times report
Reuters Health report
ABC News report


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