In April last year, the deadly Ebola virus reappeared in the Democratic Republic of the Congo (DRC), the country where the disease was first identified in 1976.
The outbreak in Equateur Province was noteworthy for two reasons. It was the first time Ebola reached an urban centre in DRC – the inland port city of Mbandaka, home to about 1.2 million people, on the Congo River. And it was also the first time Merck’s rVSV-ZEBOV vaccine was tried in an outbreak’s early stages.
On 24 July last year, the World Health Organisation (WHO) declared that the emergency was over. The official death toll was 33.
Then, just a week later, a separate Ebola outbreak was identified in Kivu region, on DRC’s eastern border. So far, more than 2300 cases have been recorded, and of those, more than 1500 have been fatal.
Numbers underestimated
Monash bioethicist Professor Michael Selgelid* says the numbers are “probably underestimates, because of cases flying under the radar – the fact that lots of the cases that are being identified weren’t known to be contacts of previously reported cases indicates that many cases haven’t been reported”.
This means surveillance is inadequate, which makes the task of vaccination – and of preventing the spread of the disease – much more difficult. Since May, the rate of infection has been accelerating, he says.
Professor Selgelid specialises in ethical issues surrounding infectious disease control.
He was on the WHO emergency committee evaluating whether last year’s smaller Ebola outbreak was a Public Health Emergency of International Concern (PHEIC). The committee, rightly in his opinion, decided it was not.
While not a member of the new emergency committee assessing the current outbreak, Professor Selgelid wonders why it hasn’t already declared the outbreak a PHEIC, given that it arguably satisfies the criteria for being one: it’s extraordinary, it poses an international risk, and it requires a coordinated international response.
He concedes that “each of these things are a matter of degree, rather than either/or, so inexactness and/or subjectivity regarding PHEIC criteria outlined in WHO’s International Health Regulations could be part of the problem. In any case, some leading experts are now are saying the outbreak may be spiralling out of control."
Only one Ebola outbreak has been bigger. It took place in West Africa in 2014-16 – mainly in Guinea, Liberia and Sierra Leone.
That event, which was declared a PHEIC (by an emergency committee on which Selgelid served as an advisor), claimed 11,310 deaths, and also accelerated the Merck vaccine’s development, providing the conditions for field trials.
The Merck vaccine has been found to be 97.5 per cent effective, when ring vaccination is used. This involves vaccinating all of a victim’s contacts (the first ring) and identifying – and sometimes vaccinating – the contacts of those contacts (the second ring).
Militia group threats
Kivu has been disrupted by warring militia groups for the past 15 years. The area shares borders with Uganda and Rwanda, with trade propelling cross-border movement. Kivu also contains about 1.4 million internally displaced people. It’s an area where distrust for authority and foreigners is high.
According to WHO, this year has already seen 42 attacks on health facilities in Kivu, with 85 health workers injured or killed. International workers are targets, too. Oxfam and the International Rescue Committee have suspended their activities in the DRC.
“It’s a sad topic, but the great news is that this vaccine appears to be highly effective, so if Ebola spreads to other places where the situation on the ground isn’t so unmanageable, it might at least be easier to control there.”
According to a survey in The Lancet, published last September, a quarter of the people in Beni and Butembo, where many Ebola cases have been detected, believe the virus to be a hoax.
Doctors without Borders have accused security forces of coercing people into treatment centres, and enforcing safe burial practices. (Traditional burial practices involve close contact with the body – a fatal custom when Ebola is the cause of death.) The implication is that the heavy-handed interventions are counter-productive; the DRC says the allegations are overblown.
Then there are the logistical obstacles. The Merck vaccine needs to be kept cold – between minus 60 and minus 80 degrees Celsius – so distributing the vaccine in an exceptionally underdeveloped war-torn tropical region is difficult.
What’s next?
What can be done? Professor Selgelid says declaring the outbreak to be a PHEIC may be useful if it attracts more funds to fighting Ebola in Kivu – funds the international relief effort desperately needs.
Establishing a ceasefire might also make it easier for health workers on the ground (a UN peacekeeping force is already deployed in the region). But with about 70 armed groups operating in the province, that will prove challenging.
The Kivu strain of Ebola has had a 67 per cent fatality rate, with women and children disproportionately affected. The DRC and WHO decided not to vaccinate pregnant or lactating women, due to uncertainty about vaccine safety. But the decision has been criticised in other quarters, and even blamed for spreading the virus.
“They’re now talking about using the existing vaccine in a broader way than ordinary ring vaccination – not just vaccinating contacts, and contacts of contacts, but maybe whole households,” Professor Selgelid says. “There has also been some testing of drugs – therapeutics, rather than vaccines.”
“It’s a sad topic, but the great news is that this vaccine appears to be highly effective, so if Ebola spreads to other places where the situation on the ground isn’t so unmanageable, it might at least be easier to control there.”
Michael Selgelid was employed by Monash at the time of writing this article.
