By Dr. Brian Blodgett
Faculty Member, Homeland Security, American Military University
The World Health Organization (WHO) finally declared the Ebola outbreak in the Democratic Republic of Congo (DRC) a public health emergency of international concern (PHEIC). The issuance of the PHEIC comes after the fourth review of the situation in the DRC, and new incidents have highlighted the cross-border spread of the disease into neighboring Uganda.
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The first known cases to appear in Uganda occurred in early June when a family of three – two children ages three and five and their grandmother – crossed the international border. The 5-year-old boy and his grandmother both died.
What Is a PHEIC?
The crisis in the DRC has been ongoing for nearly a year. But in the previous three reviews of the Ebola crisis in the DRC, it did not meet the WHO’s International Health Regulations requirements of being an “extraordinary event.” However, the most recent review found that the Ebola crisis now meets the two requirements to become a PHEIC:
- to constitute a public health risk to other States through the international spread of disease; and
- to potentially require a coordinated international response.” This definition implies a situation that is serious, unusual or unexpected; carries implications for public health beyond the affected State’s national border; and may require immediate international action.
Ebola Disease Continues to Spread
The spread of Ebola has continued unabated since May, when there were over 1,500 cases and over 1,000 deaths. The amount of new cases per week continues to grow, but fortunately this growth has not exceeded the record number of cases reached in late April when there were 126 cases in seven days.
The number of confirmed cases now exceeds 2,600 with at least 1,743 deaths – a fatality rate of 67 percent which exceeds the average Ebola fatality rate of around 50 percent. This includes 137 cases among healthcare workers, of whom 41 died. In the last 21 days, there have been 254 new cases alone.
The actual number of cases and confirmed deaths may be much higher as reported by Tariq Riebl, emergency response director for the Ebola response crisis with the International Rescue Committee, to the Associated Press. He stated, “There might be double this many cases in reality that we’re just not aware of.”
The first fatal case of Ebola in the Congolese city of Goma, home to over 2 million people, was confirmed on July 16. The fatality was a pastor who traveled from Butembo, which has the third highest rate of Ebola deaths at 16.92 percent.
With an estimated 15,000 people crossing the DRC/Rwanda border every day from Goma, a spread of Ebola to this city would be devastating. Government officials have been actively preparing for an Ebola case since last November.
The violence between local ethnic militant groups in the DRC has contributed to thousands of refugees pouring across the Uganda border. Most of these individuals live in close quarters, ripe for the spread of communicable diseases.
As a result of the PHEIC, the WHO published recommendations for affected countries, neighboring countries and all nations. According to Professor Robert Steffen, the chair of the Emergency Committee on the DRC’s Ebola, “It is important that the world follows these recommendations. It is also crucial that states do not use the PHEIC as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region.”
WHO’s recommendations for affected countries:
- Continue to strengthen community awareness, engagement, and participation, including at points of entry, with at-risk populations, in particular to identify and address cultural norms and beliefs that serve as barriers to their full participation in the response.
- Continue cross-border screening and screening at main internal roads to ensure that no contacts are missed and enhance the quality of screening through improved sharing of information with surveillance teams.
- Continue to work and enhance coordination with the U.N. and partners to reduce security threats, mitigate security risks, and create an enabling environment for public health operations as an essential platform for accelerating disease-control efforts.
- Strengthen surveillance with a view towards reducing the proportion of community deaths and the time between detection and isolation, and implementing real-time genetic sequencing to better understand the dynamics of disease transmission.
- Optimal vaccine strategies that have maximum impact on curtailing the outbreak, as recommended by WHO’s Strategic Advisory Group of Experts (SAGE), should be implemented rapidly.
- Strengthen measures to prevent nosocomial infections, including systematic mapping pf health facilities, targeting of IPC interventions and sustain support to those facilities through monitoring and sustained supervision.
WHO’s recommendations for neighboring countries:
- At-risk countries should work urgently with partners to improve their preparedness for detecting and managing imported cases, including the mapping of health facilities and active surveillance with zero reporting.
- Countries should continue to map population movements and sociological patterns that can predict risk of disease spread.
- Risk communications and community engagement, especially at points of entry, should be increased.
- At-risk countries should put in place approvals for investigational medicines and vaccines as an immediate priority for preparedness.
WHO’s recommendations for all nations:
- No country should close its borders or place any restrictions on travel and trade. Such measures are usually implemented out of fear and have no basis in science. They push the movement of people and goods to informal border crossings that are not monitored, thus increasing the chances of the spread of disease. Most critically, these restrictions can also compromise local economies and negatively affect response operations from a security and logistics perspective.
- National authorities should work with airlines and other transport and tourism industries to ensure that they do not exceed WHO’s advice on international traffic.
- The Committee does not consider entry screening at airports or other ports of entry outside the region to be necessary.
Controversy within the DRC
While the death toll continues to rise, there is an option to help limit the spread: the use of an experimental vaccine created by Johnson & Johnson. However, the DRC’s health minister, Dr. Oly Ilunga Kalenga, has played a key role in refusing to permit the vaccine’s use within the DRC.
Kalenga initially seemed to be willing to allow the Johnson & Johnson vaccine in areas not impacted by the outbreak. But in mid-July, he changed his mind at a World Health Organization meeting and said that the DRC would not approve the use of another experimental vaccine during the outbreak.
Kalenga stated in an interview, “We are in the presence of a very, very dangerous situation. We have people who don’t want to discuss [their plans] with the government. People who have no respect for ethics. And they are ready to introduce a new vaccine and to create new communications problems and trust problems with the community. . . .So I just made the decision to say no. We are not going to start a discussion again.”
Less than a week later, DRC’s President Felix Tshisekedi announced that his office would be directly supervising a multi-disciplinary team to oversee the fight against the deadly disease. This announcement led to Ilunga’s decision to resign his position. He decried his interference in the management of the Ebola response and noted that there cannot be several centers of decision-making that increased the risk of public confusion.
Kalenga also criticized the public pressure to begin using the Ebola vaccine from Johnson & Johnson. He stated, “It would be fanciful to think that the new vaccine proposed by actors, who have shown an obvious lack of ethics by voluntarily hiding important information from medical authorities, could have a significant impact on the control of the current outbreak.”
Some of the concern of using the experimental Ebola vaccine lies in the DRC’s medical leaders being unwilling to use it because its regimens differ from that of Merck’s, which created the vaccine that is currently being used to treat patients. It is not clear if the resignation of Kalenga and the newly formed multi-disciplinary team will opt to use the vaccine out of fear that medical differences will confuse healthcare providers and patients.
Merck’s vaccine is made from a live, replicating virus. It is about 97% successful in protecting a person from becoming infected, begins working in about 10 days and only requires one shot.
As of April, the vaccine is 100 percent effective for those exposed to the disease 10 days or more after being vaccinated. For patients who were exposed less than 10 days, there were only nine deaths out of 56 cases.
There are an estimated 250,000 doses of Merck’s vaccine remaining. If the dosage was cut in half, that would allow more people to be treated, a tactic that proved successful in Guinea during their Ebola outbreak in 2014-2016.
Merck refused to provide an estimate on the current number of vaccines, but stated that it could produce roughly 450,000 doses in approximately 12 months with the first 100,000 ready by January. The vaccine is made in their plant in West Point, Pennsylvania.
Johnson & Johnson’s vaccine requires two shots given two months apart and it is unknown if a person will have any protection against Ebola in between the two shots. Ensuring that individuals receive both shots is challenging, given the situation in the DRC. Paul Stoffels, the chief scientific officer for Johnson & Johnson, stated, “As a company, we stand by with 1.5 million doses of vaccine when people want to deploy them.”
However, specialists are calling for the use of Johnson & Johnson’s vaccine as concerns rise that Merck will run out of its vaccine. According to Robert Redfield, Director of the U.S. Centers for Disease Control and Prevention, “Unfortunately, there’s going to be a six to 12-month lag before there’s adequate vaccine supply, so we do project that we are going to run out of vaccine.”
What Can Be Done in the DRC?
The remoteness and limited infrastructure of the DRC areas with the outbreak, as well as the local rival militant groups, threaten responders and interrupt disease-containment efforts. Some countries consider the area to be of sufficient risk to their healthcare responders that they are refusing to send anyone to help.
At this point, there are several decisions that need to be made. The first is for President Felix Tshisekedi to allow the usage of the Johnson & Johnson vaccine in non-outbreak areas. A decision must also occur about whether or not the remaining Merck doses could be split to ensure that the maximum number of individuals receive the vaccine.
Key to the issue is the yet-to-be-mentioned aspect of funding. That includes not only funding for the current Ebola crisis, but funding for preparedness for other Ebola as well as non-Ebola outbreaks. The Infectious Diseases Society of America has urged Congress “to provide a minimum of $172.5 million for USAID’s global health security efforts and $208.2 million for the CDC Center for Global Health Division of Global Health Protection in funding for the coming year.”
Chandy John, president of the American Society of Tropical Medicine and Hygiene, in discussing the spread of Ebola outbreaks, stated, “During the previous outbreak, cases were transmitted internationally and caused a panic. In the U.S., it cost in the billions of dollars for a very small number of cases in 2014. It’s potentially a plane ride away. And I don’t mean that in a scaremongering way, but just to say that diseases now know no borders. What’s happening in the DRC matters to the U.S. for the health of our citizenry. And that’s a reason why we really need to dedicate U.S. dollars to this effort.”
While the WHO’s decision to declare a PHEIC could result in travel and trade restrictions as well as border closures, all of which could harm the economy of the DRC, it was the right decision. Given the severity of the crisis and the lack of adequate response by the DRC and the world at large during the last year, it appears likely that the crisis will continue to grow until more decisive action is taken.
About the Author
Dr. Brian Blodgett is an alumnus of American Military University who graduated in 2000 with a master of arts in military studies and a concentration in land warfare. He retired from the U.S. Army in 2006 as a Chief Warrant Officer after serving over 20 years, first as an infantryman and then as an intelligence analyst. He is a 2003 graduate of the Joint Military Intelligence College where he earned a master of science in strategic intelligence with a concentration in South Asia. He graduated from Northcentral University in 2008, earning a doctorate in philosophy in business administration with a specialization in homeland security.
Dr. Blodgett has been a part-time faculty member, a full-time faculty member and a program director. He is currently a full-time faculty member in the School of Security and Global Studies and teaches homeland security and security management courses.