Against the background of increased cross-border infection risks, the World Health Organization on Wednesday declared the Ebola virus outbreak in the Democratic Republic of the Congo to be a Public Health Emergency of International Concern (PHEIC) – a decision that may help increase aid flows to the disease epicentre but also threaten free-wheeling patterns of regional trade and travel, which are the norm today for local communities, oiling their economies.

The WHO decision, announced by Director General Dr Tedros Adhanom Ghebreyesus at an evening press conference broadcast live on Twitter, came against the backdrop of a visibly looming Ebola funding crisis, as well as more subtle disagreements over deployment of a second back-up vaccine, which some proponents say would strengthen preparedness.

WHO officials said money was not the motive for the PHEIC declaration by a special Emergencies Committee on Ebola. But Mike Ryan, WHO’s head of Health Emergencies, stressed that the Organization and its other health partners would require in excess of US$ 230 million to effectively fight the deadly outbreak in the coming months.  And that does not include other support required for security, humanitarian assistance or infrastructure.

Fresh worries about the infection spreading to Uganda also emerged on the same day, heightening concerns about international transmission. The Ugandan Ministry of Health put its public on high alert after a DRC fish trader, who had turned up sick and vomiting in a Ugandan market last week, died of Ebola on Monday upon returning home to the DRC.

In a press release, the Ugandan Ministry appealed to the public to “avoid handshaking, hugging, mass gatherings,” in the wake of the fish trader’s death in Beni, DRC, days after crossing illegally into Uganda on 11 July. Such traffic back and forth is common for not only business but also for meetings between extended families straddling parts of DRC’s porous border. That border is shared not only with Uganda and Rwanda, which have relatively robust surveillance systems, but also fragile states such as Burundi and South Sudan.

Even so, Dr Tedros stressed that regional and international borders to DRC remain open. Hindering trade or travel could spur Ebola’s spread – by driving the heavy traffic of merchants through illegal crossings where there are no infection screening measures, he said.

“I emphasise that WHO does not recommend any restrictions on travel or trade, which rather than stopping Ebola could hinder the fight,” the WHO Director General said. “Closing borders could have disastrous consequences on people who cross the border every day. Such restrictions force people to use informal and un-monitored crossings, increasing the risk of the disease.”

Dr Tedros also stressed that the DRC government was being “completely transparent” about new cases emerging – notifying neighbouring countries of any emerging risks. Under the International Health Regulations (IHR), adopted in 2005, countries are legally committed to respond to a PHEIC, including through measures such as public disclosure of disease incidence.

Uganda, meanwhile, noted that the fish trader’s Ugandan contacts were being traced and would be “immediately vaccinated.” Along with avoiding public gatherings, the Ministry urged the public to step up infection control measures such as hand-washing. It also stressed that currently, there are no known cases of new Ebola infection in the country – following the deaths of three people in June, also exposed in cross border contacts.

So far, Uganda has been a poster child for preparedness, recruiting local communities and health workers to screen travelers at its border crossings and patrolling illegal crossing points with local communities, among other measures.

However, measures overall remain inadequate, said Robert Steffan, Chair of the WHO Emergency Committee on Ebola Virus Disease, speaking at the WHO press conference, following the conclusion of the meeting of the Emergency Committee.

“Preparedness must be enhanced in neighboring countries. So far there is insufficient preparedness,” Steffan said. But he also stressed that the PHEIC declaration “should not interfere with travel and trade more than needed.”

“Explicitly, there should be no closure of borders by neighbouring countries of the DRC or anywhere else, because that would have a terrible impact on the economy of the affected regions, and negative consequences on the fight against the outbreak,” he emphasised, “This is still a regional emergency and by no way a global threat.”

Rationale of the Emergency Committee Recommendation

Referring to the written recommendations of the Committee, which had met throughout Wednesday afternoon, Steffan said that the Committee had decided to declare an emergency because of the fear of the spread of Ebola from the DRC “gateway” city of Goma along the border with Rwanda, where a pastor from Beni had travelled and fallen ill last week; recurring transmission in Beni, one of the DRC cities at the epicentre of the outbreak in the province of North Kivu; ongoing security risks to responders, and the duration of the outbreak, approaching one year.

According to data released Wednesday evening by the DRC Ministry of Health,  another 10 new Ebola cases had been confirmed in just the past two days, with a total of 2522 confirmed or probable cases of Ebola infection since the outbreak began last August, from which 1698 people have now died and 717 have survived.  Further adding to the complexity, outbreaks of measles and cholera have left over 2000 people dead in DRC between only January and July, according to WHO. Some 198 Ebola responders have been attacked, of which 7 have died.

“There is disappointment that there has been a recurrence of intense transmission in Beni, so that the geographical expansion is now some 500 km,” Steffan told the press conference. “The fight is ongoing for a full year now, and lastly the assassination of two Ebola workers demonstrates the continued risk to responders due to the security situation.”

He also voiced strong concerns about funding gaps, saying “resources have become a limiting factor in technical assistance. Increasingly there is lack of staff and of financial support. There must be more engagement by the global community to end this outbreak.”

At the same time, Steffan praised the performance of WHO and its UN partners as well as the DRC government and NGOs working in the field, saying: “The PHEIC is not declared as a reflection on the sub-optimal performance of those in the field. The rationale is to better cope with the volatile characteristics of the outbreak; the strategy is not to be changed. We need to intensify the actions and also to become more proactive.”

Indeed, the declaration seemed to immediately unleash a flurry of media attention, heightened calls for funding, and new offers of support. John Nkengasong of Africa CDC – Centres for Disease Control and Prevention said Thursday that the PHEIC alert would enable Africa CDC to deploy its African Volunteer Health Corps, a group that was used effectively in West Africa to respond to the 2014-2015 Ebola outbreak.

“This is a declaration that is usually issued when an event is extraordinary, serious and has the potential to cross beyond the country where it is and have a regional and international effect from the public health perspective,” said Nkengasong in a video message. “This is an important declaration because that changes the way that Africa Centers for Disease Control and Prevention and the Africa Union can support the Democratic Republic of Congo to respond to this outbreak.”

USAID Administrator Mark Green meanwhile called upon other donor countries to increase the funding flow to the Ebola response. In a statement posted on the USAID website and Twitter, Green noted that “USAID has provided more than $98 million to the Ebola response in the DRC since the outbreak began in August 2018.  As the single largest donor to this response, the United States encourages other donors to help bring this outbreak to an end as soon as possible.  As donors, international organizations, and NGOs continue to step up, we urge greater financial accountability and full-data sharing to provide clarity on what is being done, and what it will take, to end this outbreak.”

There were also calls in some corners for the World Bank to release more money from its Pandemic Emergency Financing Facility.  So far, some $US 20 million has been released by the Bank to support UNICEF and WHO, with WHO receiving $6.5 million, according to Ryan at the Wednesday press conference.  But some said that amount was woefully inadequate.

“So far the @WorldBank has delivered only $6.5M to @WHO for the #Ebola fight. You have a pandemic fund — release the money! What are you waiting for — another 1,000 dead? Dead Ugandans? Dead Rwandans?” tweeted Laurie Garrett, the Pulitzer Prize-winning journalist.  According to a February press release, the World Bank had announced a commitment of $US 80 million in grants and credits to the Ebola Strategic Response Plan (SRP 3) running from February to July 2019.

While WHO officials said that hundreds of millions of US dollars will be required to support a fourth phase of public health response (SRP 4) to the end of 2019, funding for the current period has only amounted to only $US 48.4 million – or less than half of the $USD 98.4 million needed, officials told Health Policy Watch.

WHO Recommends Deployment of Second Ebola Vaccine 

In what could be one major strategy shift, WHO’s Executive Director of its Health Emergencies Programme acknowledged that the Organization had resumed talks with the DRC government about introducing a second experimental Ebola vaccine, produced by Johnson & Johnson (J&J), into periphery zones of risk.

This was after DRC’s Health Minister Oly Ilunga had declared Monday at a UN high level meeting of Ebola emergencies leadership, that it would not deploy the second vaccine – for fears of creating “confusion” after a hard-fought battle to convince communities in the regions of North Kivu and Ituri that an experimental Merck vaccine now in use is indeed reliable.

Wellcome Trust’s Epidemics Lead, Josie Golding had criticised the DRC decision, saying that holding back deployment of the second vaccine could ultimately harm the response effort – particularly if the Merck vaccine, which has only been produced in a limited supply of about 300,000 doses, runs out. More than 164,000 people already have been vaccinated with the Merck preparation, although since the original vaccine dose has since been reduced by almost half, estimates vary as to how many doses are left.

In an interview today with Health Policy Watch, Golding stressed that while the J&J vaccine requires two successive doses to create immunity, it could be an important “preventative” tool complementing the Merck vaccine. Since there are 1.5 million doses available, it could also be deployed now in areas or populations at more peripheral risk, enhancing preparedness throughout the wider region.

Golding acknowledged that the concerns of the DRC government were understandable, insofar as the Merck vaccine, previously used in the 2014-15 West Africa epidemic, had developed a clear track record in the DRC emergency, provoking a very rapid and effective immune response. Notwithstanding, Golding said that the second vaccine could be used as a second-line of prevention.

“There has never been an assumption that it [the J&J vaccine] would be used directly with those that have come into contact with Ebola where the outbreak is occurring,” said Golding. “This is more about where would the disease go to, how can we think about where to use a preventative vaccine.”

“It is not about the J&J vaccine, it is about having more vaccines available, knowing that these are two vaccines for different uses. One is an emergency vaccine, the other is for prevention.”

While the J&J vaccine lacks the field testing that the Merck product has undergone, it has one further potential advantage, she added. It appears to protect against diverse strains of Ebola virus, while the Merck vaccine only protects against the strain that is presently causing the epidemic in DRC.

Acknowledging a “gap” in Merck vaccine supplies, Ryan told today’s press conference that accelerating production of the emergency vaccine is the first priority.

However, he added that “WHO supports, subject to appropriate national approvals, introduction of a second vaccine,” adding that this had previously been recommended by WHO’s Strategic Advisory Group of Experts (SAGE) on Immunization. He added that the J&J version “seems to be the most likely candidate to be deployed in the field.”

Ryan acknowledged: “Yes, the [DRC] Ministry has expressed concerns about introducing a second vaccine, mainly around confusion of the local population… We are working through those issues with them… They still remain open to deploy in areas not affected. We are working with government and [the vaccine] consortium to find the solutions that would allow the vaccine to be deployed.”

In a follow-up statement just after the press conference, Golding welcomed WHO’s expression of support for the J&J vaccine deployment, saying: “It was good to hear Dr Ryan’s remarks on the matter. We look forward to future discussions on the topic.”

She meanwhile commended WHO for the “tough decision” to declare the Public Health Emergency, saying: “As it moves into a second year, this incredibly challenging epidemic shows no sign of stopping soon. Over 1,600 people have died already, with children accounting for around a third of cases. The teams in the DRC deserve all our thanks, respect and support. There is a grave risk of a major increase in numbers, or spread to new locations – as we’ve seen this week in Goma, again in Uganda and recently close to the border of South Sudan.”

“This is perhaps the most complicated epidemic the world has ever had to face, yet still the response in the DRC remains overstretched and underfunded. The calling of a PHEIC is an opportunity for a change in the response to help stop Ebola spreading and save lives. A step-up in the response, led by the DRC and with full international support, is critical if we are to bring the epidemic to an end. This must include enhanced diplomatic, public health, security and logistic efforts as well as releasing much needed financial resources.”

“There is also a pressing need to introduce a second vaccine, by Johnson and Johnson, in the DRC – to protect communities outside of the current outbreak zone who are likely to be affected next. Countries should not wait for Ebola to spread across borders or appear on their doorstep before acting.”

-Updated 18 July 2019

Image Credits: WHO.