The governments of the United States and the United Kingdom are alerting their citizens to the possibility that there may be unreported Ebola cases in Tanzania.

The information — posted on the websites of the U.S. State Department, the Centers for Disease Control and Prevention, and Britain’s Foreign and Commonwealth Office — relates to concerning reports that a Tanzanian doctor who had been in Uganda in August and who died after her return home may have tested positive for Ebola.

The U.S. updates were posted Friday; it is unclear when the Foreign and Commonwealth Office added the warning to its webpage detailing travel advice for Tanzania.

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The moves will likely ratchet up pressure on the Tanzanian government, which has steadfastly denied having any Ebola cases. Though it has been asked by the World Health Organization to send out for external validation the tests it conducted on the dead doctor and several of her contacts who became sick as well, it has refused.

Last weekend, the WHO took the highly unusual step of alerting the world that it had received credible intelligence that Tanzania might have a case or several cases of Ebola, but that the country was denying it. The statement detailed the steps the Geneva-based agency has taken to seek information from Tanzanian authorities, who did not respond to the initial request for information for four days.

With governments starting to warn tourists about a possible Ebola risk in the country, Tanzania — which relies heavily on tourism — may begin to pay a price for its stonewalling, said Tom Inglesby, director of the Center for Health Security at the Johns Hopkins’ Bloomberg School of Public Health.

“It’s pretty clear … that kind of uncertainty and lack of confidence that the government is revealing everything will have its own very negative impact on people’s travel plans. It may not yet, but I can imagine it happening relatively soon if it’s not cleared up.”

Inglesby suggested Tanzania’s approach to the event has been illogical “and I hope they will reconsider it soon.”

“If there are no Ebola cases, and you have proof of that, then it makes absolutely no sense to hold that information back,” he said. “And if there are Ebola cases and the country is aware of that or suspects that but doesn’t provide that information, then people will stop trusting what the government of Tanzania says about the matter. Their own people will stop trusting it and others will stop trusting it.”

Rumors have swirled since mid-September about positive Ebola tests and relatives and contacts forced into involuntary quarantine. Concern about the situation has been amplified by the fact that Tanzanian health authorities are typically cooperative with international partners.

Under the International Health Regulations, a global treaty to which Tanzania is a signatory, countries are obliged to notify the WHO immediately when they have outbreaks of serious infectious diseases that could pose a risk to their neighbors and the wider world. In exchange for meeting the obligation to report, the treaty protects countries with disease outbreaks by instructing other nations not to take actions to restrict trade or travel.

The WHO has been publicly silent about the matter since it issued the statement on Sept. 21. But sources tell STAT the WHO and some national governments have been trying to get the Tanzanian government to be more forthcoming with information, using the opportunity of the United Nations General Assembly to push for transparency.

There is no information to suggest the dead woman had traveled to the Democratic Republic of the Congo, currently battling the second largest Ebola outbreak on record.

But that doesn’t preclude the possibility that she might have been infected. She might have had contact in Uganda with an unreported case there — the country borders DRC and has had several cases where infected people have crossed into the country. It is also conceivable she might have been infected through a new, as yet undetected emergence of Ebola.

Earlier this week Uganda revealed it needs more Ebola vaccine to protect health workers, a move that may signal concern that the vaccination of health workers near Uganda’s border with DRC may not be adequate to protect the health system from Ebola transmission. Ebola outbreaks often first take off when undetected cases make their way to hospitals and infect health workers who believe they are treating malaria or other diseases that can be confused with Ebola in its early stages.

The CDC’s information, which is posted in the travel health section of its website, is both mildly worded and unusual. Typically when the CDC wants to alert Americans of health risks abroad, it issues a travel notice, which are coded as level 1, 2, or 3, with 3 the highest, indicating Americans should avoid all non-essential travel to that location.

In this case, though, the information was simply added to the page that outlines travel health advice for Tanzania. There was no risk level attached to the advice.

“The ongoing risks from this event are unknown, but at this time and based on available information (which is incomplete), no travel restrictions to Tanzania are indicated,” the CDC said.

“However, travelers should remain aware of the situation and avoid direct contact with people who are ill, when possible. They should also monitor themselves for symptoms of [Ebola virus disease] (fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, unexplained bruising or bleeding) both during and for 3 weeks after travel,’’ the agency said.

The information on the State Department’s website is more succinct. Both websites outline the locations where the woman who died had traveled before her death: Songea, Njombe, and Mbeya. She died in Dar es Salaam, Tanzania’s most populous city, on Sept. 8.

Inglesby called the move by the U.S. and Britain the basic responsibility of governments to their citizens.

“Given that WHO has issued its statement that says that it’s concerned about the possibility of Ebola cases, it would be irresponsible for the U.S. government or the U.K. or other countries that have advice for travelers to Tanzania to not include that in their warnings and their precautions for travelers,” he said.

This story has been updated to add that the United Kingdom is also alerting its citizens to the possibility of Ebola in Tanzania.
Correction: An earlier version of this story wrongly identified the capital of Tanzania. It used to be Dar es Salaam but now is Dodoma. It also said the U.K. travel advice was posted on Public Health England’s website; it was in fact posted on the website of the Foreign and Commonwealth Office.

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