A long-time veteran of Ebola responses has raised serious concerns about the way the current outbreak in the Democratic Republic of the Congo is being handled, saying he fears transmission of the virus may not be stopped in the region.
In a commentary published in the journal Lancet Infectious Diseases, Dr. Pierre Rollin criticized the response for a lack of coordination and urged the DRC health ministry to accept more outside help to support laboratory services and generate real-time genetic sequencing of viruses, something authorities there have been unwilling to do so far.
The state of the outbreak, Rollin said, has not improved and unless it does, the virus could become endemic — entrenched — in the region. That view is not widely shared by other Ebola experts, he acknowledged in an interview Friday with STAT. Still, he sees it as a real possibility.
“I don’t think the virus will be endemic in one town or one aire de santé (health area) or zone de santé (health zone). It’s going to keep moving until it moves to the place where we cannot go at all, and we have no clue of what’s going on,” said Rollin, who retired from the Centers for Disease Control and Prevention in January.
“If we don’t catch up and if we don’t get a good grasp on what’s going on with the transmission, it’s going to keep going,” he said flatly.
The outbreak, which has been raging for a year, has resulted in nearly 2,800 infections and more than 1,850 deaths to date.
Gary Kobinger, another long-time Ebola researcher and responder, doesn’t agree with Rollin’s prediction that the virus will become entrenched in northeastern DRC. But he does share his friend’s concerns about the way the outbreak response is structured — including DRC’s reluctance to accept outside laboratory help.
“If I could just give this one [piece of] advice, just open your arms and just go get the strengths wherever they are,” said Kobinger, who led the work to develop the Ebola drug ZMapp and who is director of the Infectious Disease Research Center at Laval University in Quebec.
One of the major criticisms in Rollin’s commentary relates to the fact that there is not one sole database used to keep track of all known cases and their contacts, an essential tool needed to trace where the virus is moving through the population.
“The different and mainly incomplete databases combined with the absence of accurate and up-to-date chains of transmission makes case counts, monitoring, and intervention difficult or even impossible,” he said.
“Parallel databases should not exist,” wrote Rollin, who for decades was a fixture in Ebola outbreak responses.
Rollin spent some time in the outbreak zone at the beginning of this epidemic, but was pulled back to Kinshasa — DRC’s capital — after the U.S. government deemed the area where the virus is spreading too dangerous for U.S. government employees. That prohibition, issued in late August, is still in place.
Despite the fact he has retired, Rollin has deep roots in the Ebola response community and has an up-to-date understanding of how this outbreak response is functioning — a fact that was reflected in the World Health Organization’s reaction to the publication of his critique.
“As experts such as Pierre Rollin know, the outbreak in Ituri and North Kivu is occurring in a complex environment with an extraordinary range of challenges. WHO, UN and other partners are continually improving our response and will take this feedback on board,” the agency said in an emailed statement.
Finding and cutting the chains of transmission is the foundation of a successful Ebola response. The goal is to find cases and care for them in isolation, where they cannot infect others; identify, vaccinate, and monitor their contacts so new cases are spotted and isolated as quickly as possible when they become symptomatic (and infectious); and bury the dead safely.
That work has never been fully functional in this outbreak, which is occurring in a part of DRC that has been a conflict zone for more than two decades. The Ebola response workers are unable to access some affected villages or neighborhoods and have been attacked at times. People in the region have a deep distrust of both their government and outsiders, which also hinders the efforts to find cases and identify who should be offered Ebola vaccine.
Rollin noted in his commentary that the teams that go out to determine who should be offered vaccine — contacts of cases, and contacts of the contacts are eligible — and the surveillance teams trying to piece together where in the community Ebola is spreading are separate and mostly do not share information with one another. That means worried and grieving families end up talking with two different teams of people, asking them the same questions, he noted.
Rollin suggested a single combined team should be doing this work and that the data should be logged in a single database.
Kobinger, who traveled to the outbreak zone in late April as part of a mission to assess the response for the WHO, said the current setup is encouraging different players to hoard data so that they can publish scientific papers. “People have a vested interest in not sharing data so that they can publish them,” he said.
The upshot, Rollin said, is that the percentage of new cases that come from contact lists hasn’t really improved since early in the outbreak, when it was recognized as a major problem.
“For the last eight months there is no change in the ratio between the new confirmed case being ‘known, followed’ or ‘known, not followed,’ or ‘unknown,’” he said. “We are behind. We stay behind for at least a year. We never succeed to get ahead.”
He also expressed concern about the fact that the response effort is not identifying what are known as probable cases — people who died of Ebola-like symptoms but were never tested. Finding those cases helps the response get back on the tail of the virus. But the number of probable cases — 94 — hasn’t changed in weeks, Rollin said.
Kobinger concurred: “This is the most evident symptom that proper data are not being collected.”
“You cannot have 50% or 40% or even 10% of the people dying in the community without being associated with a chain of transmission and not have a huge amount of probable cases,” he insisted, suggesting that by now there should be hundreds of probable cases on the rolls.
“Where are these cases? Well, they are feeding all these chains of transmission that are not being detected right now,” Kobinger said.
Another problem Rollin raised relates to so-called nosocomial transmission of Ebola — people who are contracting the virus when they seek health care from a traditional healer, a local clinic, or a community hospital that is not set up to identify or safely treat Ebola patients.
Reuse of medical equipment — including syringes — is too common in these facilities, resulting in people who sought care for one ailment contracting Ebola after being given an injection with a contaminated needle.
The problem is exacerbated by the fact that many people with Ebola are turning to these health facilities for care instead of going to Ebola treatment centers, where they can be treated safely and where experimental Ebola drugs are available.
The ETCs, as they are called, are being eschewed by many of the sick, who see them as places where people go to die.
The Ebola response has been working for months to try to educate staff of these facilities of the dangers of reusing medical equipment, but the lessons haven’t taken root.
“Even if the infection prevention and control efforts have yielded some progress, the relatively large proportion of cases due to reuse of material (e.g., syringes, needles, and perfusion tubes) is unacceptable,” Rollin wrote.