The long-running and dangerous Ebola outbreak in the Democratic Republic of the Congo — which spilled over into neighboring Uganda this week — is an emergency for the country and a threat to its neighbors, but doesn’t constitute a global health emergency, the World Health Organization concluded on Friday.
The decision, which quickly garnered criticism in some quarters, was made on the recommendation of a panel of outside experts, called an emergency committee.
Dr. Preben Aavitsland, acting chair of the committee and one of the people who wrote the rules governing public health emergencies of international concern after the 2003 SARS outbreak, said there was extensive debate within the group, but in the end they agreed the declaration was not needed and could worsen the situation on the ground.
“This is not a global emergency. It’s an emergency in the Democratic Republic of the Congo — a severe emergency. And it may affect neighboring countries,” said Aavitsland, a senior physician at the Norwegian Institute of Public Health.
He noted the additional powers that come with an emergency declaration are not needed at this time. It allows the WHO to disclose to other countries information about a disease event even if the country experiencing the outbreak doesn’t wish to share. And it gives the WHO director-general authority to issue temporary recommendations, effectively instructing other countries not to cut off trade and travel with the affected nation.
In previous instances when a public health emergency of international concern — called PHEIC for short — has been declared, the WHO’s recommendations on travel and trade have sometimes been ignored. Countries have interpreted the declaration as a threat. Many, for instance, stopped issuing visas to people from Ebola-affected countries during the West African Ebola outbreak of 2014-2016. And most international airlines stopped flying into those countries.
“So it was the view of the committee that there is really nothing to gain by declaring a PHEIC, but there is potentially a lot to lose,” Aavitsland said.
The WHO director-general, Tedros Adhanom Ghebreyesus, who was in the Congolese capital, Kinshasa, on Friday, accepted the committee’s recommendation.
“Although the outbreak does not at this time pose a global health threat, I want to emphasize that for the affected families and communities, this outbreak is very much an emergency,” said Tedros, as he is known. He will travel Saturday to Butembo, one of the recent transmission hot spots and a place where attacks on Ebola response team workers have occurred.
Some global health experts have been calling for months for this outbreak to be declared a PHEIC. The lack of such a declaration is potentially depriving the Ebola response of badly needed assistance and donor cash, they have argued.
The latter is badly needed. The WHO said the response has been hampered by a lack of funding; the agency currently has a $54 million funding gap for this work. Efforts to prepare neighboring countries for cross-border spread, for instance, has not proceeded at the pace it ought to because funding for the work isn’t there, said Dr. Mike Ryan, executive director of the WHO’s emergencies program, which is leading the response in conjunction with the DRC ministry of health.
Dr. Jeremy Farrar, director of the Wellcome Trust, said the declaration of a PHEIC might have helped on the funding front and would have generated more attention globally for the outbreak.
“I don’t think it should change one iota of what we do” to curtail spread of the virus, he said. “But we live in a political world and we live in a world of communication.”
The North Kivu outbreak likely started in late April 2018 but was only recognized as Ebola in late July. The official declaration that an outbreak was underway in DRC, which had combatted nine earlier Ebola outbreaks, was made on Aug. 1.
Since then, more than 2,100 cases and 1,400 deaths been reported, making this the second largest Ebola outbreak on record. And while it is still less than one-tenth of the size of the massive West African outbreak that ran from 2014 to 2016, it is proving to be potentially more difficult to control.
The epidemic is occurring in northeastern DRC, in the provinces of North Kivu and Ituri, which hug the country’s borders with South Sudan, Uganda, and Rwanda. The area has been engulfed in conflict for more than two decades, limiting the response’s access to some communities where the virus has been circulating.
Since late February, community anger has been directed at the response teams; at least five workers have been killed. Suddenly an outbreak that was inching downward exploded, with more cases in April and May than in the five previous months combined.
Despite those challenging conditions, the emergency committee decided in mid-April— as it had in October — that an outbreak that hadn’t yet crossed international borders did not meet the criteria to be declared a global health emergency.
This week it did cross a border — into Uganda.
A family — the mother is Congolese, the father Ugandan — were traveling from the funeral of her father, who died of Ebola in DRC. They slipped into Uganda on Monday. First their 5-year-old son, then his grandmother and 3-year-old brother, were diagnosed with Ebola. The older boy and the grandmother died of their infections; the 3-year-old and other family members who traveled with the group were returned to DRC.
Several of DRC’s neighbors have been preparing for months for the possibility that infected people might cross into their territory. Uganda, which has fought five previous Ebola outbreaks, has vaccinated nearly 5,000 health and front-line workers at about 165 health facilities located near the border; it has also built nine Ebola treatment centers near its western border.
Those preparations appear to have paid off this week. The family sought care at a hospital where health workers suspected Ebola and sent the family to one of the treatment centers, at Bwera. The health workers at both facilities had been vaccinated.
But whether any other people in Uganda have contracted the virus in this incident remains to be seen. Several dozen people in Uganda are believed to have had contact with the family. Health authorities there are tracking those people to offer vaccine and monitor their health for three weeks to see whether they will develop the disease.
WHO’s Ryan said 10 high-risk contacts have been identified so far in Uganda and the vaccination effort there will begin Saturday.
In related news, Tedros welcomed an announcement from vaccine manufacturer Merck that it would make an additional 450,000 doses of the experimental Ebola vaccine being used in DRC. More than 130,000 people have been vaccinated so far and there is always concern that supplies of the vaccine, which is not yet being made to commercial scale, will run low.
Merck said that after discussions with the U.S. government and the WHO it would use a U.S.-based plant that makes pilot batches vaccines for the company to manufacture the additional doses. It takes about a year from start to finish to make this vaccine.
The WHO recently learned that it could halve the amount of vaccine given to each person and still get an effective response. Based on the lower dosage, there are currently a quarter-million doses of vaccine at the ready, Ryan said, and a further 100,000 doses will be available by the end of the year.
It is unbelievably gutless / careless that the WHO did not at minimum stop traffic out of the infected zones ….. what are they waiting for / afraid of ? Is the WHO’s own legal wording a culprit ?? Or is the outbreak simply too far from home to worry too much about it? Just wait till the disease is carried to a western nation via an airplane ………. there WILL be full-bore panic, and finger pointing etc. But then it may be too late. What does it take for any “top” institution to figure out and implement protective action that is unique for a dangerous and escalating situation in a country that can not control its citizens and health providers ???
This is the conceptual problem posed by the notion of “public health event of international concern.” There is a communication miscue that makes this sound as if a serious health event in a local area is only of major concern if it affects “the international community.” The disease surveillance and response issues surrounding this north Kivu and environs outbreak are complex and worthy of unique and novel solutions that depart from the traditional public health epidemiologic responses. That in itself should be worthy of international cooperation.
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