WHO declines to designate Ebola outbreak as international emergency

GENEVA — The World Health Organization on Friday declined to declare an international health emergency over a rapidly accelerating outbreak of the deadly Ebola virus in the Democratic Republic of the Congo, even as case counts climb dramatically in several large cities.
 
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WHO Director-General Tedros Adhanom Ghebreyesus said Friday that he had accepted the conclusions of an advisory emergency committee, meeting here at WHO's world headquarters, which decided the outbreak had not yet reached the level of international concern.
 
"Everyone here agrees that we must do everything possible to end this outbreak as soon as possible," Tedros said at a press conference. "The fact that a [public health emergency of international concern] has not been declared makes no difference to our commitment or our ability to fight this outbreak."
 
Only four public health emergencies of international concern — or PHEICs — have ever been declared. The designation, introduced in 2005, was first applied to a swine flu outbreak in 2009. It was later applied to a polio outbreak in 2014, an Ebola epidemic in three West African nations in 2014, and the global spread of the Zika virus in 2016.
 
The current Ebola virus outbreak has infected more than 1,200 people in two eastern provinces in the Democratic Republic of the Congo, according to the country's health ministry. More than 760 people have died, making it the second-deadliest Ebola outbreak in modern history, after the West Africa epidemic.
 
The virus has not jumped international borders to South Sudan, Uganda or Rwanda — countries that neighbor the two provinces most heavily affected — but public health officials are still nervous about its possible spread, both inside and outside of Congo.
 
"Whatever the official status of this outbreak is, it is clear that the outbreak is not under control and therefore we need a better collective effort. The virus has not spread to neighboring countries so far, but the possibility exists," said Gwenola Seroux, the emergency manager at Medecins Sans Frontieres, or Doctors Without Borders.
 
Public health officials say the situation in North Kivu and Ituri provinces is among the most complex and challenging they have ever experienced. Decades of ethnic conflict have left more than a million people internally displaced, and factions battling for control have put health responders and the Congolese military in harm's way.
 
"This is a very, very different environment to be going after a virus," Mike Ryan, executive director of the WHO's Health Emergencies Program, told The Hill in an interview. "We're trying to deal with the most dangerous virus in the world in the most dangerous place in the world."
 
Eight months after Congo formally announced the new outbreak, the number of cases appears to be growing at a faster pace. More than 200 people have been infected in the last three weeks alone, the WHO said, most of them in the twin cities of Butembo and Katwa, home to about 1.5 million people.
 
The outbreak began in the city of Beni, north of Butembo and Katwa, where attacks from Islamist militants threatened the populace and health care workers. The number of cases in Beni appeared to drop after the arrival of United Nations peacekeeping troops, who provided security and helped international groups build trust with local civic leaders.
 
But the virus began to gain a foothold in the southern twin cities, where Mai-Mai militias provide security and are deeply integrated within the community. Ryan said the community's needs in Butembo and Katwa were different from those in Beni, and international health care workers had not yet earned the residents' trust. Two Ebola treatment centers were attacked last month, though those facilities are operational once more.
 
Health care workers must build inroads in those communities where they operate, especially in places like North Kivu, long neglected by the far-off central government in Kinshasa. Without that trust, residents are suspicious of outsiders, and the vaccines they carry to fight off the virus.
 
"The Ebola response has exposed the absence of an ongoing humanitarian response," Ryan said. "If you've got access [to the community], you have a chance. If you don't have access, you haven't got a chance."
 
UNICEF is leading community engagement programs in the region, while other nongovernmental organizations like Interpeace are working to build trust through dialogue task forces and contracts between communities and the international responders. Doctors and nurses on the ground in Butembo and Katwa have taken students and community leaders on tours of Ebola treatment centers, to combat misinformation and show off their medical capacity.
 
The grim case statistics show just how crucial earning trust can be. In Beni, where someone infected with the virus now seeks care within an average of two days, the case mortality rate is about 53 percent. In Buetmbo and Katwa, where it can take up to six days for an infected person to seek treatment, the mortality rate is about 75 percent.
 
Health officials say the region's neglected public health system and the transient nature of its population are both complicating matters and spreading the virus. 
 
About 30 percent of those who have been infected caught the virus in a health care facility, some of which are little more than homes or hidden storefronts, where needles are reused repeatedly.
 
And about half of all cases are transmitted through contact with someone from a different health zone, the sign of a highly mobile population with widespread family and social networks. A recent case in the village of Komanda, more than 100 miles north of Butembo, occurred when a traveler showed symptoms while visiting family.
 
"A given family in Katwa will have connections to three or four other places," Ryan said.
 
Women and children under the age of 18 years old have been disproportionately struck by the virus. About 57 percent of all cases have occurred among women, who typically care for sick relatives in Congolese society. And nearly 30 percent of all cases have occurred among children.
 
North Kivu and Ituri provinces are important trading centers with their international neighbors, Uganda, South Sudan and Rwanda. The virus has not yet crossed international lines, though health officials -- including those from the American Centers for Disease Control and Prevention -- have begun vaccinating front-line health care and security workers in those countries, just in case the virus does jump borders.
 
Health care teams have administered an experimental -- but apparently effective -- vaccine to nearly 98,000 people in Congo, including more than 20,000 in both Katwa and Beni and another 12,000 in Butembo. The teams are operating what is called a ring vaccination campaign, in which those who have come into contact with an Ebola victim are vaccinated, as are the contacts of those contacts. 
 
Some of those contacts have resisted the vaccines, though about 90 percent of those offered the vaccine have accepted it, Ryan said.
 
But in a province of about eight million residents, it is not possible to reach everyone, and only about 175,000 doses of the vaccine remain in stock. Merck, the pharmaceutical company that manufactures the vaccine, has said it will take months to rebuild its supply.
 
Ryan, careening from meeting to meeting at WHO's headquarters, said he still has hope that the virus can be contained before it becomes endemic to the population — though he acknowledged the response will require months more work and massive new investment from the international community.
 
"I have to believe that we will end transmission," he said. But, he added: "There's no magic bullets here. There's no unicorn."