The Democratic Republic of Congo (DRC) is experiencing the second largest Ebola outbreak in history. This week has been the worst by far, with more than 100 new cases in the last 5 days. Since the outbreak began last summer, there have been more than 1,500 cases, with just over 1,000 deaths.
The DRC’s Ministry of Health and the World Health Organization, along with international partners and nongovernmental organizations, are on the ground working to control the outbreak: helping provide care for the sick while trying to track down their contacts and working to vaccinate those contacts and their contacts. They are also trying to improve communication with affected communities about how Ebola is spread and how to prevent it.
Although the DRC has successfully contained Ebola outbreaks before, this one is happening in part of the country with limited infrastructure and active and dangerous militias whose actions threaten responders and have led to interruptions in disease-containment efforts. While many countries judge the situation to be too high risk to send people to help — a WHO responder was killed in a recent attack — the WHO and partners are doing dangerous response work in the country.
Despite months of this courageous and determined work, the number of new cases per day has risen steeply this week. “There might be double this many cases in reality that we’re just not aware of,” Tariq Riebl, emergency response director for the Ebola response crisis with the International Rescue Committee, told the Associated Press.
In the 2014-2016 Ebola outbreak in West Africa, the epidemic really began to accelerate when daily case counts reached the numbers we are seeing now in the DRC. It seems to us that this outbreak now meets the definition of a public health emergency of international concern, though it has not yet been officially deemed one. Whether or not such a declaration is made, there is no debate that the situation is dire and worsening. It’s a critical time to consider what more the rest of the world should be doing to help all those who are working to contain the outbreak. We believe these three steps would help.
First, countries and international donors must provide the finances the DRC, WHO, and their partners need to contain this outbreak. WHO depends on countries and donors to respond to emergencies. On April 30, WHO Director Tedros Ghebreyesus said in a statement that “WHO and its partners cannot tackle these challenges without the international community stepping in to fill the sizeable funding gap.” In the same statement, the WHO said that only half of the currently requested funds have been received, “which could lead to WHO and partners rolling back some activities precisely when they are most needed.”
It is hard to understand how WHO has been put into this position. Following the flawed early global response to the 2014 Ebola epidemic, countries established a Contingency Fund for Emergencies so the organization would not have to raise funds to mount a response to deadly outbreaks. But global contributions to the fund have fallen short of the annual target, and the WHO is once again having to ask for funds for this essential work.
The possibility of a rollback in response due to limited resources is ominous. In the past, interruptions in the work of responding to an outbreak have been followed by surges in new cases. The mere suggestion of that happening should provoke a reappraisal by leading governments and international organizations about what it will take to stop this Ebola outbreak. The West Africa Ebola outbreak ended up costing billions of dollars to contain. WHO is asking for a small fraction of that sum now. If it isn’t provided, efforts to control the outbreak will likely be far more expensive later, in terms of lives lost and funds needed.
Second, new security strategies are needed to allow public health workers to contain the virus. Violence in the region is a central reason the epidemic continues to worsen despite broad containment efforts. The DRC and the UN peacekeeping force, known as MONUSCO, have not been able to control the violence enough to allow public health response activities to proceed without interruptions. Failing to develop a security strategy risks the possibility that Ebola could spread to neighboring countries, a situation that would greatly exacerbate Ebola’s human and economic costs and further erode security in the region.
Third, governments, donors, and relevant leaders from the pharmaceutical industry should expand the Ebola vaccine supply and allow for wider use beyond the current vaccination strategy. No vaccine was available to fight previous Ebola outbreaks. There is now an investigational vaccine, produced by Merck, which appears to be safe and effective. It is being used primarily for people who have been in contact with individuals who developed Ebola, contacts of contacts, and health care workers.
This is a good strategy but it’s contingent on knowing who most of the Ebola patients are and who most of their contacts are. Unfortunately, there is too much uncertainty in both categories. Throughout the outbreak, a high percentage of cases (56% this week) were not diagnosed until individuals died in the community. This means that many case contacts are not being found or being offered vaccine.
A larger-scale vaccination campaign could take place. It would protect many more people and perhaps allow for the response to get ahead of Ebola’s spread. In addition, reports of vaccine refusal among case contacts, and even among health care workers who are at greater risk of infection, indicate that broader use of a vaccine beyond the high-priority groups may be needed to increase the level of protection in the communities where Ebola is occurring or is likely to head.
A larger vaccination strategy would require substantially more vaccine to be produced. Merck has said it has limits on its production capacity. National governments and international organizations need to work with industry to devise and fund new options that might augment the supply such as: providing resources for new production facilities, expanding the supply through reduced dosing, enlisting additional outside manufacturers of the vaccine, and/or fast-tracking other Ebola vaccines through development and regulatory processes.
It’s possible that control efforts will bring the Ebola outbreak in the DRC under better control in the coming weeks. But it is also possible that the situation could precipitously deteriorate. Government leaders and international organizations that have needed expertise and the means to help finance the response should reassess whether they are doing all they can do, either by themselves or in a coalition of the willing.
Leaders should start planning with the assumption that Ebola could get much worse quickly in the DRC. If they do, maybe together they can help the DRC, WHO, and partner organizations change the direction of this outbreak.
Tom Inglesby, M.D., is the director of the Johns Hopkins Center for Health Security at the school’s Bloomberg School of Public Health. Jennifer Nuzzo, Dr.P.H., is a senior scholar at the center.