With new case numbers rising at an alarming rate, the World Health Organization said Wednesday it will again look at whether the Ebola outbreak in the Democratic Republic of the Congo should be declared a global health emergency.

The announcement that a panel of outside experts — a so-called emergency committee — will meet Friday to debate the question came on a day when the DRC health ministry was expected to say 18 new Ebola cases had been identified. That marked the highest one-day increase in this epidemic, now in its ninth month.

“We’re at a critical time in this outbreak,” Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy, told STAT.

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Osterholm said it was necessary to rethink the approach being taken to contain the epidemic, which was declared on Aug. 1. “Doing the same thing over and over again does not appear to be working,” he said.

This will be the second time an emergency committee has been asked to advise WHO Director-General Tedros Adhanom Ghebreyesus on whether this outbreak meets the criteria to be declared a Public Health Emergency of International Concern, known in global health circles as a PHEIC. The committee met in October and though it described the outbreak as very worrying, it recommended against declaring a PHEIC at that time.

To date the outbreak has not spread to other countries, which is thought to be one of the reasons a PHEIC has not been declared.

But it is occurring in what is effectively a conflict zone, a reality that time and again has impeded the response team’s ability to bring transmission to a halt. As of Tuesday there have been 1,186 cases and 751 deaths.

Every time there has been a surge in violence there has been a corresponding sharp rise in cases. But whereas the violence was directed at Congolese soldiers or the United Nations peacekeeping operation in the outbreak area last fall, increasingly the attacks have been directed at the Ebola outbreak response itself.

In late February, Ebola treatment centers at Katwa and Butembo were firebombed by armed assailants, putting both out of commission for a time. Doctors Without Borders, which had been operating those treatment centers, withdrew its staff, saying it could not ensure their safety. Both centers have since reopened and are being operated by the DRC ministry of health and the WHO.

Since those attacks, case numbers have soared, and an outbreak that looked in February like it was coming under control now looks far from it.

Community resistance to the control measures known to stop Ebola transmission remains high in Katwa and Butembo, hotspots that are fueling the outbreak at this point. Many infected people are refusing to go to treatment centers for care, choosing instead to stay at home. That accelerates spread of the disease because the people who care for these patients will almost inevitably become infected themselves in the process.

There was hope that an experimental Ebola vaccine, made by Merck, would help to contain the outbreak. And WHO officials insist that but for the vaccine, this outbreak would be many times more severe than it already is. More than 97,000 doses of the vaccine have been administered so far in this outbreak.

But failings of the response are undermining the vaccine’s effectiveness. The vaccine is being used in what is called a ring vaccination approach — it is being offered to people who are known contacts of cases and the contacts of the contacts, as well as health workers and other frontline workers. The idea is to prevent spread of the virus by protecting people who are in contact with cases.

For that approach to work, the Ebola response needs to be able to identify as many contacts as possible. But in many cases they have been unable to do the contact tracing work needed to draw up detailed lists; cases have occurred in neighborhoods or villages where it is unsafe for them to work. As a result, many people who should have been vaccinated have not appeared on the vaccination list.

The prolonged length of this outbreak has raised concerns that supplies of the vaccine might run out. Merck has promised to try to maintain a stockpile of 300,000 doses. At the time that figure was struck, 300,000 doses seemed like a large cushion. But this outbreak has made it clear the size of the stockpile will need to be revisited.

On Tuesday the company revealed that to date it has shipped to the WHO 145,000 doses of the vaccine and has roughly another 195,000 doses that are ready to be shipped as needed. An additional 100,000 doses should be ready to be shipped within the next three months, Merck said.

The company said it continues to work to produce doses of the vaccine and is exploring options to make even more if needed.

Merck has started the process of applying to both the Food and Drug Administration and its European counterpart, the European Medicines Agency, to license the vaccine, which is currently known as V920.

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  • The first question that needs to be asked is, “What true difference in response would declaration of a PHEIC bring that is not already happening?”

    The second question, which should have been answered transparently months ago is, where is the data on vaccine effectiveness? We aren’t talking about the studies from West Africa but what is going in the DRC. WHO has ignored multiple requests, and that issue is not going away. The Ugandans, Rwandans, and Sudanese are counting on that vaccine actually working as advertised. And the healthcare systems of Europe and US have an expectation that requires proactive management. Meanwhile we still have reports of healthcare workers dying without indication of whether they were vaccinated.

    Bottom line: unless you have evidence of uncontrolled expansion to Uganda, Rwanda, or Sudan and within proximity of an international airport, you are going to have a hard time justifying global emergency relevance. Beware of media hype when trying to form a balanced assessment.

    James M Wilson V, MD FAAP
    Director, Nevada Medical Intelligence Center
    University of Nevada-Reno

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