One year into the DRC Ebola outbreak – is there an end in sight?

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The outbreak of Ebola in the Democratic Republic of Congo (DRC) has seen over 2612 cases and 1756 mortalities since it was first announced by the WHO on 1 August 2018 (data as of 23 July 2019 [1]). In addition, there have been many challenges compounding the outbreak – from weak health systems, poor security and endemic mistrust, to controversy over whether the outbreak constituted a Public Health Emergency of International Concern (PHEIC).

One year on we ask, what have the major milestones been of the DRC Ebola outbreak? And where are we now; is there an end in sight?

The beginning

The DRC had already tackled and ended an Ebola outbreak in 2018 [2]. Beginning in May in Bikiro this outbreak was quickly controlled, ending on 24 July. However, just over a week after the Bikiro outbreak was announced as having ended, a new outbreak was reported (1 August 2018) in the region of North Kivu, over 2500km from Bikiro. On 7 August genetic analysis demonstrated that the two strains weren’t closely linked, confirming this was a new outbreak. Ebola is endemic to the DRC and the August outbreak marked the tenth outbreak the country had seen since the virus’ discovery in 1976.

Ring vaccination began in the DRC on 21 August 2018, and even at these early stages public health officials were warning of security concerns within the DRC, something that would become a major challenge for the outbreak response [3].

The first PHEIC statement

On 17 October 2018 the Emergency Committee was convened by Dr Tedros Adhanom Ghebreyesus, WHO Director General, for the first time regarding the DRC Ebola outbreak. A PHEIC, defined as “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”, has to be declared by the WHO Director General following a recommendation of the International Health Regulations Emergency Committee [4].

Following the meeting it was decided that a PHEIC would not be declared, the Committee cited concerns that a PHEIC could led to trade and travel bans in the DRC, that could in turn hinder the response. However, they stated they were “deeply concerned by the outbreak” and the emphasized that the response should be “intensified” [5].

Reconsideration

In the months following the initial PHEIC decision, it was reported that this Ebola outbreak had become the second worst ever recorded, only smaller than the 2014–2016 West African outbreak, which claimed over 11,000 lives. Following these reports, many public health experts and scientists began calling for a reconsideration of the initial decision [6].

On 12 April 2019 a spike in cases prompted Tedros Adhanom Ghebreyesus to reconvene the Committee for the second time. Once again, the Committee reached the same decision – the outbreak did not constitute a PHEIC [7]. Committee member Robert Steffen (University of Zurich, Switzerland) commented that “by definition,” an outbreak remaining within a country’s borders “is not of international concern.” [8]. Again, the Committee expressed “deep concern” about transmission in specific areas, with Dr Tedros stressing that an additional US $104 million was needed to close the funding gap and carry out the WHO’s plans through to the end of July [9].

This decision, made for the second time, drew scrutiny from those in the field, including actors in the response.

The arguments for and against

The response to the DRC Ebola outbreak is complex, including many issues of security and community mistrust, as highlighted by the Committee. These factors led to divergent opinions on whether a PHEIC should be announced, and if it were to be, whether it would make a difference.

The argument for announcing a PHEIC includes that the announcement requires a coordinated international response, galvanizing international attention, resources and funds. With extra funding necessary to ensure a sufficient response to the outbreak, a PHEIC was viewed by some as a concrete way to secure additional finance. In addition, it would refocus the world’s attention on this health crisis – a phenomena seen in the 2014–2016 outbreak once a PHEIC was announced.

However, Committee member Steffen commented that: “A PHEIC should not just be a money-making decision,” [8]. In addition, much of the violence during the DRC’s Ebola response has been motivated by money, with some individuals in the country holding the view that the WHO is profiting from the outbreak, thus an injection of more money could compound these issues. Moreover, many of the armed militia groups in the region fund themselves by kidnapping aid worker and other individuals for ransom – if it were known that more money was available, would this galvanize more attacks?

Other arguments against announcing a PHEIC included that, although one of the stipulations of the label is that it shouldn’t impact travel or trade with the affected country [4], previous PHEICs have seen just this effect. For example, in the 2014–2016 outbreak there were examples of visas being denied for individuals from affected countries [11]. This would not only be damaging for the DRC and its citizens but, if restrictions were imposed, it could also seriously hamper the outbreak response by hindering the travel of aid workers and supplies.

Uganda cases – PHEIC meeting take three

Following the second decision the DRC Ebola outbreak rumbled on, hitting another milestone on 13 June 2019, when the outbreak crossed an international border and the first Ebola cases were confirmed in Uganda [10]. The cases comprised a 5-year-old child, a 50-year-old grandmother and a 3-year-old brother all of whom had travelled over the border from the DRC. Unfortunately, following confirmation both the index case and the grandmother were reported to have died. On the news, Jeremy Farrar, Director of the Wellcome Trust (London, UK), commented: “This epidemic is in a truly frightening phase and shows no sign of stopping. We can expect and should plan for more cases in DRC and neighboring countries.”

In response to the cases in Uganda, the Emergency Committee were reconvened for the third time, meeting on 14 June. They stated that the cluster of cases in Uganda was not unexpected, and the containment of the cases was a testament to the importance of preparedness, again expressing “deep concern” about the ongoing outbreak and bringing attention to the lack of adequate funding and human resources. Despite this, the Committee felt that although the outbreak is an extraordinary event, with a risk of international spread, the ongoing response would not be enhanced by a PHEIC announcement. Thus, the decision of the Committee and the WHO Director General was once again that the outbreak was not a PHEIC, to the frustration of many [12].

Farrar commented: “Declaring this a PHEIC would have raised the levels of international political support which has been lacking to date, enhanced diplomatic, public health, security and logistic efforts as well as released more financial resources to support the incredibly brave and committed teams working in [the DRC].”

A tipping point?

A month later, on 15 July a case of Ebola was confirmed in Goma, a city with a population of over 2 million [13]. The case was a pastor who had travelled from Butembo, where he had seen Ebola cases, to Goma, a city on the border with Rwanda. Despite assurances that all contacts had been vaccinated Dr Tedros once again called the Committee together, and this time the Goma cases appeared to be a tipping point. The Committee cited that Goma was a gateway to Rwanda, the rest of the DRC, and the world. In addition, they expressed disappointment about delays in funding that had constrained the response. Combined, it was felt that this was enough to merit a PHEIC [14,15].

Dr Tedros commented: “Extraordinary work has been done for almost a year under the most difficult circumstances. We all owe it to these responders – coming from not just WHO but also government, partners and communities – to shoulder more of the burden.” However, he also warned: “The PHEIC should not be used to stigmatize or penalize the very people who are most in need of our help.”

What impact has the PHEIC had?

The PHEIC announcement has been reported to have generated more funding for the response, with the World Bank (DC, USA) readying US $300 million – funds that are much needed [16]. Moreover, the announcement has certainly re-focused the world’s attention on the outbreak, but will it have unintended consequences?

Despite a recommendation alongside the PHEIC against travel and trade restrictions it has been reported the Rwanda has closed it’s border with the DRC, following a second case in the city of Goma [25]. The DRC’s President’s office stated that it regretted this decision “which runs counter to the advice of the World Health Organization.” In addition, it has been reported that Saudi Arabia has stopped issuing visas to individuals from the DRC [26].

The decision has also precipitated political maneuvering within the DRC. After the announcement DRC President Felix Tshisekedi took over the Ebola response from the Ministry of Health, appointing Jean-Jacques Muyembe, General Director of the Democratic Republic of the Congo National Institute for Biomedical Research, to the response effort. This triggered the Minister of Health, Oly Ilunga, to resign, stating that moving the response away from his department could jeopardize the consistency, stability and efficiency of the Ebola response [17]. Ilunga also referenced ongoing pressure to introduce another Ebola vaccine to the response – an experimental candidate from Johnson & Johnson (NJ, USA).

The vaccine currently in use, which is produced by Merck (NJ, USA), is also experimental and thus-far at least 143,000 doses have been administered int he DRC Ebola outbreak. Some suggest that the introduction of a second vaccine would ensure an adequate stock, although it has been reported that Merck have 250,000 more doses [18]. However, Ilunga, and others, have argued that introducing a second vaccine with a different regimen could cause confusion – fueling suspicion around vaccination. Moreover, the Johnson & Johnson vaccine requires two doses [19], a factor that could be challenging in an unstable region with a constantly shifting population. With the decision now out of Oly Ilunga’s hands, we will have to wait and see whether the second vaccine will be introduced.

The challenges

The DRC Ebola outbreak currently faces some difficult challenges, many of which were alluded to in statements from the Emergency Committee. First the DRC has poor infrastructure and an under-resourced health system – it is currently dealing with several other outbreaks, including measles and cholera [20,21]. Both of these are comparable to the Ebola outbreak, and this fact appears to be feeding into a general sense of mistrust in communities – why is Ebola receiving so much attention?

Institutional trust and misinformation is the second issue, with a population-based survey of 961 adults in Benu and Butembo carried out in September 2018 revealing that only 349 individuals thought local authorities could be trusted, 230 believed rumors that the Ebola virus does not exist, and an even higher proportion believed the outbreak was fabricated for financial gains (312 individuals) or to destabilize the region (371 individuals) [22].

Violence and instability are factors known to impact public trust and to aid the spread of misinformation, and this is the third major challenge. Oxfam have estimated that across the DRC 12.8 million individuals are in need of humanitarian assistance, due to conflict and displacement [23], and violence has also been aimed specifically at the Ebola resonse. Since January approximately 200 attacks on treatment centers and healthcare workers have been reported, causing five deaths and 58 injuries [24]. Thus, not only does the unstable environment endanger response workers and aid misinformation, it also presents issues in reaching affected communities in rural and remote areas.

Oxfam’s Country Director in the DRC, Corinne N’Daw explained: “The unending violence in the region is devastating the lives of hundreds of thousands of people, preventing them from getting essential services, like healthcare, and ultimately hampering the larger humanitarian and Ebola response.”

What does the future hold?

Commenting on the anniversary of the outbreak, Dr Matshidiso Moeti, WHO Regional Director for Africa, stated: “This first year is not a milestone we ever wanted to reach.” The issues are complex and interconnected, Moeti referred to them as “unprecedented challenges”, but most experts agree that trust must be built with affected communities and the response must involve local leaders and engage patients and their families. In addition, a coordinated and comprehensive approach will be required, as Moeti stated: ” We call for solidarity to end the outbreak.”

In a joint statement regarding the anniversary, Dr Tedros commented: “The challenges to stopping further transmission are indeed considerable. But none are insurmountable. And none can be an excuse for not getting the job done. The United Nations and partners are continuing to ramp up the response in support of the Government and to further bolster joint action.”

Looking at the numbers, there is certainly no end in sight for this outbreak – between 3 July and 23 July, 64 health areas within 18 health zones reported new cases [1], totaling 242 confirmed individuals. Moreover, on 31 July, a second case of Ebola was confirmed in Goma [25] – a miner who had traveled from the province of Ituri to the city – with the case later dying. Dr Tedros commented: “This latest case in such a dense population center underscores the very real risk of further disease transmission, perhaps beyond the country’s borders.”

With cases still appearing, and appearing in critical areas, there is  much left to be seen moving forwards: will political maneuvering in the DRC impact the response? Will the announcement of a PHEIC allow more funding and coordination? Will a second vaccine be tested? And finally, will new measures help keep these cases contained?

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