The Ebola outbreak in the Democratic Republic of Congo does not constitute a public health emergency of international concern. CNN reports that this is according to Robert Steffen, chair of the World Health Organisation (WHO) International Health Regulations Emergency Committee, who said there is no added benefit in declaring an emergency at this time.
“If it stays within a country, it is, by definition, not an issue of international concern,” he explained. However, he emphasised that this does not downplay the situation and said everything must still be done to stop this outbreak. The committee’s decision was “almost unanimous,” Steffen said. The WHO defines a public health emergency of international concern as “an extraordinary event” that constitutes a “public health risk to other States through the international spread of disease” and “to potentially require a coordinated international response.”
The outbreak, which began in August, is the second largest and second deadliest on record, with 1,206 total cases and 764 total deaths as of Thursday of last week, according to the DRC Ministry of Health. A 2014 outbreak in West Africa killed more than 11,000 people, according to WHO. The report says a total 1,711 probable cases of Ebola had been reported when a public health emergency of international concern was declared on August 8, 2014, for the West Africa epidemic.
Without the emergency declaration, the world is now “on pace to really have a repeat of West Africa,” said Jennifer Nuzzo, a senior scholar at the Johns Hopkins Centre for Health Security.
The report says in 2014, there was no treatment or vaccine to prevent the spread of Ebola. Due to research advancements since then, experimental treatments and vaccines have been used in Congo. To date, 358 patients have recovered from the illness, and more than 97,000 vaccines have been administered, which some believe has helped limit the spread of the outbreak.
WHO spokesperson Tarik Jašarević identified the reasons why the Emergency Committee was reconvened last week: “A rising number of security incidents have been restricting access to affected communities in key areas, for vital operations such as surveillance, case investigation, contact tracing and vaccination.” These factors led to a surge in cases in recent weeks after a period of decline, Jašarević said. “Calling the committee does not automatically lead to a declaration of a Public Health Emergency of International Concern,” Jašarević added.
In an update from WHO early Friday, it said: “Though the risk of spread within the country and to neighbouring countries is very high, the risk remains low globally. WHO continues to advise against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on currently available information.”
The epicentre of the outbreak is North Kivu and Ituri provinces, among the most populous in the nation and bordering Uganda, Rwanda and South Sudan, according to the WHO. The report quotes the WHO as saying that not only is North Kivu experiencing this deadly Ebola outbreak, but long-term conflict smoulders there, with 50 armed groups causing intermittent violence. The UN public health agency estimates that more than a million refugees and internally displaced people are traveling through and out of North Kivu and Ituri. Meanwhile, bursts of violence, the burning down of Ebola treatment centers and the kidnapping of health workers have plagued the effort from the start.
“The continued increase in cases this past week reflects the complex reality of conducting an effective outbreak response in a geographically difficult area with a highly fluid population, intermittent attacks by armed groups, and limited healthcare infrastructure,” WHO said.
But, the report says, some argue that legal criteria have been met. Lawrence O Gostin, a professor of global health law and director of the WHO Collaborating Centre on Global Health Law at Georgetown University, wrote that, given worsening conditions in Congo, Tedros “should have declared a (public health emergency of international concern) and made bold new recommendations for bringing the DRC Ebola epidemic under control.” “The legal criteria for declaring a (public health emergency of international concern) have been met for several months now,” he said. “The International Health Regulations do not require actual international spread but only the potential for international spread.”
The report says the International Health Regulations, which are legally binding for all WHO member states, aim is to help the global community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. “Clearly, the DRC epidemic could spill over to neighbouring countries and even to other parts of Africa, even potentially through air travel to North America and Europe,” Gostin said.
An Emergency Committee meeting for the outbreak that was convened in October did not declare an emergency, though the committee’s report warned about the potential for further degradation. “I think the situation has degraded much, much further,” Nuzzo said. At the time, it was said that the emergency committee had examined the available information and determined the outbreak was of regional but not global concern. “We do have some optimism that this outbreak… will be brought under control in reasonable time,” Steffen said in October.
Nuzzo believes there were additional reasons: “It’s hearsay, I can’t prove it, but the rumours are that there was worry about political blowback.” She explained that when international emergencies are declared, countries take actions that are not permitted under international health regulations, such as restricting travel and trade, “in an attempt to try and protect themselves.”
The worry in October was that declaring a public health emergency of international concern would lead to travel restrictions, and this would make it harder for health workers to move into and out of the Congo, she said. The report says the rumours seem to explain Friday’s decision, if not October’s. “We also felt declaring a public health emergency of international concern would not aid the situation, it might actually even complicate it,” Steffen said.
However, Nuzzo said, “although it’s understandable that they’re trying to prevent unintended consequences,” that’s not what the declaration is supposed to be about. Rather, it is “supposed to be based on science and what the science says.”
The report says without a declaration of emergency, there is no pressure placed on countries to acknowledge that this is significant global problem and that officials need to be investing all the necessary resources, including money, technical expertise and security forces, to combat it. Opponents say that declaring a public health emergency of international concern doesn’t do much, Nuzzo said. “Nonetheless, they are the basis of our International Health Regulations, so deciding not to use (the emergency declaration) has other downstream consequences.”
One consequence of not declaring an emergency is that “it establishes an expectation that countries develop the capabilities to be able to detect when an important event is occurring,” Nuzzo said. Another is that it undermines WHO’s future abilities when confronting an international crisis.
Due to violence, the US State Department has not allowed the US Centres for Disease Control and Prevention to deploy staff to the epicentre. The CDC has staff in-country, far from the epicentre, and does not provide information regarding location in order to protect the privacy and safety of health care professionals.
Nuzzo said she doesn’t disagree “that the situation is dangerous, but I do think that insufficient work has been done to figure out a way to send them safely and to protect them.” “At the end of the day, there’s only a few hundred WHO staff in the field. At the height of Ebola in West Africa, there were well over 1,000 CDC employees deployed.”
According to the report, she gives WHO and humanitarian organisations such as Médecins sans Frontières (Doctors without Borders) and the International Rescue Committee “enormous credit” for their “tireless” work. “They can only do so much, and they also need CDC’s technical expertise,” she said. “WHO is competent but new at this, and CDC has been doing this for 40 years.”
The CDC said it is committed to helping end the outbreak and is preparing to be engaged in response activities for the long haul.
Gostin said that “each day that passes, precious lives die, including brave health workers. Were it not for a highly effective vaccine, the DRC epidemic could easily have been as severe as in West Africa, and we can’t let this DRC epidemic slip out of control.”
“I was deeply disappointed that, under these harsh conditions and with so many deaths, that WHO did not do more to break from the usual mould.”
The Ebola outbreak in the DRC was worsening as trust in the response effort faltered, an IoL report quotes the International Federation of Red Cross and Red Crescent Societies (IFRC) as saying. On Tuesday of last week, 18 new Ebola cases were confirmed – the highest single day figure in the now eight month-long outbreak, said IFRC. The DRC Health Ministry also reported that 10 died people from Ebola on Tuesday, including eight who died in their communities having not sought treatment and support.
“This is a very distressing development,” said Emanuele Capobianco, IFRC’s director of health and care. “The bottom line is that Ebola is now spreading faster, and many people are no longer seeking care. It is clear that some vulnerable communities do not trust Ebola responders.”
Redoubling efforts to engage with the communities was critical, according to Capobianco. “Trust can be built by going community to community, working with local leaders and villagers, listening to their concerns with empathy, and incorporating their feedback and preferences into how we work,” he is quoted in the report as saying.
In-depth community engagement was central to the Red Cross operation in North Kivu and Ituri provinces in eastern DRC, where more than 700 Red Cross volunteers from Ebola-affected communities were at work, according to the statement. Volunteers had reached more than 1m people with locally adapted information and collected more than 130,000 “pieces” of community feedback.
“Our research and experience show that when in-depth community engagement takes place, acceptance of outside assistance improves significantly,” said Capobianco.
Intense community outreach and engagement in and around the city of Butembo had a direct and significant impact on the willingness of communities to welcome, and in some cases, request Red Cross “safe and dignified burial teams”, the IFRC said.
The report says the safe burial of people who have died of Ebola is a critical intervention in preventing disease spread.
“The efforts of the Red Cross and other responders are also hampered by considerable funding shortfalls. Last month, the (IFRC) and the International Committee of the Red Cross launched a revised emergency appeal for Sf31.5m to support response activities in DR Congo as well as preparedness activities in neighbouring countries. So far, only Sf11.1m have been received,” the IFRC is quoted in the report as saying.