The Ebola outbreak in the Democratic Republic of Congo does not constitute a public health emergency of international concern, the World Health Organization’s director-general, Dr. Tedros Adhanom Ghebreyesus, said Friday.
Robert Steffen, chairman of the WHO International Health Regulations Emergency Committee, said there is no added benefit in declaring an emergency at this time. “If it stays within a country, it is, by definition, not an issue of international concern,” he explained. However, he emphasized that this does not downplay the situation and said everything must still be done to stop this outbreak.
The committee’s decision was “almost unanimous,” Steffen said.
WHO defines a public health emergency of international concern as “an extraordinary event” that constitutes a “public health risk to other States through the international spread of disease” and “to potentially require a coordinated international response.”
The outbreak, which began in August, is the second largest and second deadliest on record, with 1,206 total cases and 764 total deaths as of Thursday, according to Congo’s Ministry of Health. A 2014 outbreak in West Africa killed more than 11,000 people, according to WHO.
A total 1,711 probable cases of Ebola had been reported when a public health emergency of international concern was declared on August 8, 2014, for the West Africa epidemic. Without the emergency declaration, the world is now “on pace to really have a repeat of West Africa,” said Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security.
In 2014, there was no treatment or vaccine to prevent the spread of Ebola. Due to research advancements since then, experimental treatments and vaccines have been used in Congo. To date, 358 patients have recovered from the illness, and more than 97,000 vaccines have been administered, which some believe has helped limit the spread of the outbreak.
Differences between then and now
WHO spokesman Tarik Jašarević identified the reasons why Tedros reconvened the Emergency Committee on Friday: “A rising number of security incidents have been restricting access to affected communities in key areas, for vital operations such as surveillance, case investigation, contact tracing and vaccination.” These factors led to a surge in cases in recent weeks after a period of decline, Jašarević wrote in an email Thursday.
“Calling the committee does not automatically lead to a declaration of a Public Health emergency of International Concern,” Jašarević added.
In an update from WHO early Friday, it said that “Though the risk of spread within the country and to neighboring countries is very high, the risk remains low globally. WHO continues to advise against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on currently available information.”
The epicenter of the outbreak is North Kivu and Ituri provinces, among the most populous in the nation and bordering Uganda, Rwanda and South Sudan, according to WHO.
During the past 21 days (ending April 9), a total of 207 probable new cases were reported in 40% of the 141 health areas affected to date, WHO reported in a Thursday update.
Not only is North Kivu experiencing this deadly Ebola outbreak, but long-term conflict smolders there, with 50 armed groups causing intermittent violence, according to WHO. The UN public health agency estimates that more than a million refugees and internally displaced people are traveling through and out of North Kivu and Ituri. Meanwhile, bursts of violence, the burning down of Ebola treatment centers and the kidnapping of health workers have plagued the effort from the start.
“The continued increase in cases this past week reflects the complex reality of conducting an effective outbreak response in a geographically difficult area with a highly fluid population, intermittent attacks by armed groups, and limited healthcare infrastructure,” WHO said in its update.
Legal criteria have been met, some argue
Lawrence O. Gostin, a professor of global health law and director of the WHO Collaborating Center on Global Health Law at Georgetown University, wrote in an email that, given worsening conditions in Congo, Tedros “should have declared a [public health emergency of international concern] and made bold new recommendations for bringing the DRC Ebola epidemic under control.”
“The legal criteria for declaring a [public health emergency of international concern] have been met for several months now,” he said. “The International Health Regulations do not require actual international spread but only the potential for international spread.” The International Health Regulations, which are legally binding for all WHO member states, aim is to help the global community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.
“Clearly, the DRC epidemic could spill over to neighboring countries and even to other parts of Africa, even potentially through air travel to North America and Europe,” Gostin said.
An Emergency Committee meeting for the outbreak that was convened in October did not declare an emergency, though the committee’s report warned about the potential for further degradation. “I think the situation has degraded much much further,” Nuzzo said.
Why didn’t the director-general declare an emergency in October?
At the time, it was said that the emergency committee had examined the available information and determined the outbreak was of regional but not global concern. “We do have some optimism that this outbreak… will be brought under control in reasonable time,” Steffen said in October.
Nuzzo believes there were additional reasons: “It’s hearsay, I can’t prove it, but the rumors are that there was worry about political blowback.” She explained that when international emergencies are declared, countries take actions that are not permitted under international health regulations, such as restricting travel and trade, “in an attempt to try and protect themselves.”
The worry in October was that declaring a public health emergency of international concern would lead to travel restrictions, and this would make it harder for health workers to move into and out of the Congo, she said.
The rumors seem to explain Friday’s decision, if not October’s. “We also felt declaring a public health emergency of international concern would not aid the situation, it might actually even complicate it,” Steffen said.
However, Nuzzo said, “although it’s understandable that they’re trying to prevent unintended consequences,” that’s not what the declaration is supposed to be about. Rather, it is “supposed to be based on science and what the science says.”
During the outbreak in Congo, about 60% of those who have become sick due to the Ebola virus – which causes fever, severe headache and in some cases hemorrhaging – have died. On average, past outbreaks have had a 50% fatality rate.
Possible consequences of the decision
Without a declaration of emergency, there is no pressure placed on countries to acknowledge that this is significant global problem and that officials need to be investing all the necessary resources, including money, technical expertise and security forces, to combat it, Nuzzo said.
Opponents say that declaring a public health emergency of international concern doesn’t do much, she said. “Nonetheless, they are the basis of our International Health Regulations, so deciding not to use [the emergency declaration] has other downstream consequences.”
One consequence of not declaring an emergency is that “it establishes an expectation that countries develop the capabilities to be able to detect when an important event is occurring,” Nuzzo said. Another is that it undermines WHO’s future abilities when confronting an international crisis.
Due to violence, the US State Department has not allowed the US Centers for Disease Control and Prevention to deploy staff to the epicenter. The CDC has staff in-country, far from the epicenter, and does not provide information regarding location in order to protect the privacy and safety of health care professionals.
Nuzzo said she doesn’t disagree “that the situation is dangerous, but I do think that insufficient work has been done to figure out a way to send them safely and to protect them.”
“At the end of the day, there’s only a few hundred WHO staff in the field. At the height of Ebola in West Africa, there were well over 1,000 CDC employees deployed.”
She gives WHO and humanitarian organizations such as Doctors Without Borders and the International Rescue Committee “enormous credit” for their “tireless” work.
“They can only do so much, and they also need CDC’s technical expertise,” she said. “WHO is competent but new at this, and CDC has been doing this for 40 years.”
The CDC said it is committed to helping end the outbreak and is preparing to be engaged in response activities for the long haul.
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Gostin said that “each day that passes, precious lives die, including brave health workers. Were it not for a highly effective vaccine, the DRC epidemic could easily have been as severe as in West Africa, and we can’t let this DRC epidemic slip out of control.”
“I was deeply disappointed that, under these harsh conditions and with so many deaths, that WHO did not do more to break from the usual mold.”