Perspective

WHO: Ebola outbreak not an international health emergency despite deaths in Uganda

Tedros Adhanom Ghebreyesus 
Tedros Adhanom Ghebreyesus
Photo of Robert Redfield 
Robert R. Redfield

Today, an emergency committee convened by WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, for the third time, determined that the current Ebola virus outbreak in the Democratic Republic of the Congo, or DRC, does not meet the criteria to be declared a Public Health Emergency of International Concern, or PHEIC, despite reports of the first cross-border cases and deaths.

“The committee has decided for a third time that the current and ongoing outbreak in the DRC does not meet the criteria for a [PHEIC],” Tedros said during a press conference. “Although it does not pose a global health threat, this outbreak is very much an emergency.”

The outbreak, which has been ongoing in an area of conflict in the northeastern DRC since August 2018, has left up to 2,108 people infected and 1,411 dead, according to the most recent update provided by the country’s health ministry. The health ministry also reported cases have crossed over into neighboring Uganda, where a 5-year-old boy and his 50-year-old grandmother have died.

Infectious Disease News previously reported that the boy crossed the border into Uganda from the DRC on June 9. Health care workers identified that he might have Ebola, and he was admitted and isolated at a hospital with an Ebola treatment unit, according to the Ugandan health ministry. WHO said a rapid response team has been dispatched to the area to identify anyone who may have been in contact with the boy and noted that this was the first case of Ebola confirmed outside the DRC in the current outbreak.

“Although the spread to Uganda is tragic, it is not a surprise,” Tedros said. “We have said since the beginning that the risk of cross-border spread is high, but the fact that it has taken this long is a testament to efforts of both sides of the borders.”

WHO officials said teams are working to identify all contacts of the cases in Uganda so that proper actions can be taken to stop any further spread.

The CDC has lent its support to the outbreak response by activating its Emergency Operations Center (EOC) on Thursday.

“We are activating the [EOC] at CDC headquarters to provide enhanced operational support to our expanded Ebola response team deployed in DRC,” CDC Director Robert R. Redfield, MD, said in a press release. “Through CDC’s command center we are consolidating our public health expertise and logistics planning for a longer term, sustained effort to bring this complex epidemic to an end.”

Preben Aavitsland, MD, acting chair of the emergency committee, said during the press conference that at-risk countries should improve preparedness for managing imported cases, cross-border screening should continue with improved quality and WHO should continue to monitor population movement. He added that all priority countries should put vaccination approvals in place so optimal vaccine strategies can be implemented rapidly.

“While it is an extraordinary event, we believe that the ongoing response would not be enhanced by declaring [a PHEIC],” Aavitsland said. “The committee provided a range of advice to WHO and member states and strongly urges countries and partners to heed this advice.” – by Caitlyn Stulpin

Disclosures: Aavitsland, Redfield and Tedros report no relevant financial disclosures.

Tedros Adhanom Ghebreyesus 
Tedros Adhanom Ghebreyesus
Photo of Robert Redfield 
Robert R. Redfield

Today, an emergency committee convened by WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, for the third time, determined that the current Ebola virus outbreak in the Democratic Republic of the Congo, or DRC, does not meet the criteria to be declared a Public Health Emergency of International Concern, or PHEIC, despite reports of the first cross-border cases and deaths.

“The committee has decided for a third time that the current and ongoing outbreak in the DRC does not meet the criteria for a [PHEIC],” Tedros said during a press conference. “Although it does not pose a global health threat, this outbreak is very much an emergency.”

The outbreak, which has been ongoing in an area of conflict in the northeastern DRC since August 2018, has left up to 2,108 people infected and 1,411 dead, according to the most recent update provided by the country’s health ministry. The health ministry also reported cases have crossed over into neighboring Uganda, where a 5-year-old boy and his 50-year-old grandmother have died.

Infectious Disease News previously reported that the boy crossed the border into Uganda from the DRC on June 9. Health care workers identified that he might have Ebola, and he was admitted and isolated at a hospital with an Ebola treatment unit, according to the Ugandan health ministry. WHO said a rapid response team has been dispatched to the area to identify anyone who may have been in contact with the boy and noted that this was the first case of Ebola confirmed outside the DRC in the current outbreak.

“Although the spread to Uganda is tragic, it is not a surprise,” Tedros said. “We have said since the beginning that the risk of cross-border spread is high, but the fact that it has taken this long is a testament to efforts of both sides of the borders.”

WHO officials said teams are working to identify all contacts of the cases in Uganda so that proper actions can be taken to stop any further spread.

The CDC has lent its support to the outbreak response by activating its Emergency Operations Center (EOC) on Thursday.

“We are activating the [EOC] at CDC headquarters to provide enhanced operational support to our expanded Ebola response team deployed in DRC,” CDC Director Robert R. Redfield, MD, said in a press release. “Through CDC’s command center we are consolidating our public health expertise and logistics planning for a longer term, sustained effort to bring this complex epidemic to an end.”

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Preben Aavitsland, MD, acting chair of the emergency committee, said during the press conference that at-risk countries should improve preparedness for managing imported cases, cross-border screening should continue with improved quality and WHO should continue to monitor population movement. He added that all priority countries should put vaccination approvals in place so optimal vaccine strategies can be implemented rapidly.

“While it is an extraordinary event, we believe that the ongoing response would not be enhanced by declaring [a PHEIC],” Aavitsland said. “The committee provided a range of advice to WHO and member states and strongly urges countries and partners to heed this advice.” – by Caitlyn Stulpin

Disclosures: Aavitsland, Redfield and Tedros report no relevant financial disclosures.

    Perspective

    Dr. Tedros Adhanom Ghebreyesus was wise to reconvene the emergency committee for the third time to review the Ebola epidemic in the DRC. Previous committees did not declare a PHEIC.
    The emergency committee should have recommended declaring the epidemic in the DRC a PHEIC. It is now time for bold action. The international community has lacked any sense of urgency, essentially allowing WHO's Health Emergency Department and a few nongovernmental organizations to fight the Ebola battle in the DRC. This has come with enormous risk to life and safety for first responders.

    The cross-border spread of Ebola to Uganda was a pivotal event. The criteria for a PHEIC have been met for many months. The legal criteria for a global emergency do not require international spread but only a high risk, which has been crystal clear for a long while. But now WHO can no longer fail to raise a global alarm. Not only is Uganda now identifying confirmed and suspected cases, but also there is a risk of spread to other border countries like Rwanda, along with the entire region. If the DRC epidemic is not contained soon, it could spread to regions around the world, including North America and Europe.

    We have been trying to quell a dangerous epidemic using the same public health game plan that has worked in the past. But it isn't working now, and it won't. Standard strategies like case identification, vaccination and treatment can’t succeed in a complex humanitarian crisis like the situation in the DRC. Responders in the field are facing intense violence, along with deep community mistrust. They can’t get into the hot zone because of escalating violence, and they can’t find cases to vaccinate and treat because families are hiding the sick. There has been no clear strategy to break the vicious circle of disease, violence and distrust.

    It seems WHO hasn’t called an emergency because it fears repercussions in the form of travel restrictions. They also believe a PHEIC provides them with no additional power or resources. But the status quo is no longer tenable. It is time to sound a global alert.

    WHO needs to mobilize resources and political will. During the West African Ebola epidemic, President Obama secured a $1 billion emergency appropriation, led a U.N. Security Council resolution and deployed the military in a noncombat role. Other countries like France and the United Kingdom followed the lead set by the U.S. None of that has happened yet, quite the opposite because the Trump Administration has banned the CDC from the hot zone. There is a major funding deficit for the response. There is a shortage of vaccines. This is all crippling the response.

    So what do we need? We need a sense of international urgency, mobilizing resources and deploying experienced personnel. We need smart diplomacy from the U.S. State Department and U.N. to ameliorate the violence. We need a bottom-up social engagement of the community.

    There has to be a secured “safety zone” for health personnel to enter villages to identify cases and vaccinate those at risk. U.N. peacekeepers, with the mission and training explicitly to protect health personnel and work with local communities, should maintain safety.

    Until we galvanize international support and we change the playbook, we can expect the DRC epidemic to either spin out of control or, more likely, we will have a steady drumbeat of needless suffering and death for the next year, maybe much longer.

    For each day that passes, precious lives are lost, including brave health care workers. Were it not for a highly effective vaccine, the DRC epidemic could easily have been as severe as the one in West Africa. Since West Africa, and with a new Director-General, WHO has transformed itself. This is a pivotal moment for the future of WHO. Declaring an emergency would have been the first crucial step. Much work to be done to fight this epidemic with a sense of urgency and purpose.

    • Lawrence O. Gostin, JD
    • Professor, Georgetown Law
      Director, O’Neill Institute for National and Global Health
      Georgetown University

    Disclosures: Gostin reports no relevant financial disclosures.

    Perspective

    The reported Ebola cases in Uganda are at the border district with DRC, and all cases already have been contained. Uganda has seen similar epidemics frequently in the past and is well prepared regarding containment, and I believe our Ugandan colleagues will act quickly to contain the Ebola outbreak much like they have done previously. With the exception of the first epidemic in northern Uganda many years ago, public health officials and clinicians often get these controlled very quickly.
    Uganda has an outstanding public health infrastructure, and the CDC is actively present in this country to fight epidemics including hemorrhagic fevers side by side with our Ugandan colleagues. The Ugandan Ministry of Health has been monitoring the situation, too, and today they had a meeting of the national taskforce to review the response and next steps. Our colleagues from Makerere School of Public Health have representatives in this task force.
    Uganda is not in a civil war like the DRC, and an effective vaccine is available and has been given to the Ugandan health care works in advance of any outbreak. I don’t think the emergency committee should declare the outbreak a PHEIC, but regardless, all nations, particularly the United States, should make more resources (financial and expert health workers) available to the DRC to stop the source of this lingering epidemic as soon as possible.

    • Majid Sadigh, MD
    • Director of Global Health
      Christian J. Trefz Family Endowed Chair in Global Health
      Western Connecticut Health Network
      Associate professor, University of Vermont, Larner College of Medicine

    Disclosures: Sadigh reports no relevant financial disclosures.

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