How world health officials stopped a potentially catastrophic outbreak

How world health officials stopped a potentially catastrophic outbreak
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Days after an outbreak of the deadly Ebola virus was identified in May in remote parts of the Congo River Valley, Tedros Adhanom Ghebreyesus landed at a tiny single-runway airport in Mbandaka.

Ghebreyesus, the new director general of the World Health Organization (WHO), put himself in the midst of a viral hot zone to deliver a message: The global public health community would throw its weight behind the effort to stop the spread of the disease as fast as possible. They would not repeat the mistakes that led to thousands of deaths in West Africa just a few years earlier.

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Two months later, in July, Congo formally declared an end to the outbreak, after 42 days in which no new cases were identified. An Ebola epidemic that once threatened to travel up and down the mighty Congo River was instead snuffed out at its source.

At the heart of the response was the WHO. A few years ago, the agency had come under intense international scrutiny for its lackluster response to a 2014 outbreak in Guinea, Liberia and Sierra Leone. That delay likely cost thousands of lives.

This time, the WHO sent hundreds of people to a remote corner of the Congolese jungle in a matter of days, coordinating a massive response with partner organizations like the local health ministry, the U.S. Centers for Disease Control and Prevention (CDC) and Doctors Without Borders.

In interviews over the past two weeks, a dozen senior public health officials offer near-unanimous praise for an organization that was once riven by internal bureaucratic strife.

“They answered the outbreak quite fast, and they deployed a huge amount of resources quite early on,” Axelle Ronsse, who oversaw the response for Medecins Sans Frontieres (MSF), known in English as Doctors Without Borders, said in an interview from her office in Brussels.

MSF deployed 470 doctors, nurses and virus hunters to build Ebola treatment units, operate lab facilities and distribute a vaccine to front-line health-care workers. The group sounded one of the earliest alarms about the outbreak in West Africa four years ago, when they begged the WHO to take more-aggressive action.

“The big difference from us is that last time, if we spoke about the West Africa outbreak, we were calling a lot of time to get help,” Ronsse said. “It was completely the other way around [this time]. They were there.”

Years of bureaucratic bloat had bled power away from WHO headquarters in Geneva, distributing it to regional and country offices around the world. When Ebola hit West Africa, the WHO’s management arm and its emergency operations arm were in different units, creating roadblocks that prevented quick action.

Following that outbreak, several outside panels recommended a series of wholesale changes — changes that have largely taken place. For example, the management and emergency operations arms were merged.

So when when Ebola was identified in Congo three months ago, there was little doubt that the Geneva headquarters would descend on the Equateur Province to do work that might have once been the purview of the less-well-funded regional office.

“I see this as a really significant proof of concept of the reforms that WHO began making after the 2014 outbreak,” said Jeremy Konyndyk, a former head of the U.S. Agency for International Development’s Office of Foreign Disaster Assistance who sits on an oversight panel that advises WHO’s governing board. “They are much more operational now than they were then. They have much better informational systems than they did then.”

Top WHO officials acknowledged both during and after the West Africa outbreak that their agency had fallen short, in part, they said, because the world expected them to be capable of mounting a response to such a significant outbreak — a capability WHO did not have.

“We had a number of commissions calling for WHO to be more operational,” said Ibrahima-Soce Fall, who leads WHO’s Health Emergencies Programme in Brazzaville, capital of the Republic of Congo. “We realized the expectation from developing countries was higher than what WHO could actually do.”

“There’s been a pretty significant cultural shift and a pretty significant increase in capability and reorganization that came directly out of those post-Ebola reforms,” Konyndyk said.

Congo's Health Ministry first raised the alarm that Ebola was once again breaking out on May 3, when a cluster of 21 cases of an undiagnosed hemorrhagic fever was identified in the rural Ikoko Impenge area, south and east of the Congo River. The first teams of virus-hunters, including health ministry, WHO and MSF officials, arrived in the region two days later.

By May 8, Ebola had been identified in lab tests in the Congolese capital, Kinshasa.

The virus soon spread to Bikoro, a larger regional center a few miles from Ikoko Impenge. Then it spread to Mbandaka, a major city that sits right on the Congo River, which stretches almost 3,000 miles.

“We were very concerned at the beginning when we had cases in Mbandaka,” Fall said. “Mbandaka is a very big city with a population of close to 2 million. Mbandaka is close to the Congo River, and you can see the traffic on the Congo River.”

Within days, MSF had set up the first Ebola treatment units in Bikoro and Ikoko Impenge. WHO managed contributions and a massive influx of government personnel from Canada, Germany, Italy, Norway, the United Kingdom and the United States. The CDC sent nine people from its satellite office in Kinshasa.

Victims who survived the disease were brought on as liaisons to the community, to show that treatment and recovery was possible.

As vaccines flowed in, so too did about 50 Guinean health-care workers who had distributed the vaccines in West Africa toward the tail end of the 2014 outbreak. In total, more than 3,400 front-line health-care workers and those who had come into contact with Ebola victims were vaccinated.

In Mbandaka, responders set up a vaccination clinic in a low-slung concrete building. They stayed in the only two hotels of any significant size, the Nina Hotel and the Hotel Benghazi, where rooms lacked air conditioning but did not lack cockroaches. At medical clinics, they relied on fuel for generators shipped in by United Nations air transport to keep the lights on.

Those who were on the ground in Mbandaka credited the Congolese Health Ministry, which has responded to nine Ebola outbreaks since the virus was first identified in 1976.

“What’s very different about this outbreak as compared to other outbreaks is you really see the Congolese taking the lead with the laboratory work and taking real leadership and running this outbreak and showing the world how much they do know how to organize an outbreak response,” said Anne Rimoin, a UCLA epidemiologist who runs a research program in Kinshasa in conjunction with the Health Ministry.

The last patient developed symptoms on June 2, and within weeks the mood in Mbandaka had turned from fear to cautious optimism. By July 24, the country had passed two consecutive incubation periods without a new case, a sufficient amount of time to declare Congo Ebola-free.

All told, 54 probable and confirmed cases were identified. Thirty-three of those people died.

Some public health officials said they were relieved, and surprised, that the virus did not spread beyond Mbandaka.

“We are a bit surprised it did not extend,” MSF’s Ronsse said. “We are happy, but we cannot explain it. We were quite lucky that it didn’t extend more.”

Ghebreyesus, the WHO’s director general, was in Kinshasa once again on Tuesday, when Health Minister Oly Ilunga declared the latest outbreak over.