This week, the Ebola outbreak in the Democratic Republic of Congo (DRC) became the second largest ever recorded. As we have discussed in previous Outbreak Thursday posts, DRC successfully contained an outbreak of Ebola in July, but efforts to contain a second, unrelated outbreak that emerged only weeks later have so far been unsuccessful, in part, due to ongoing security challenges.

At 426 total cases (379 confirmed, 245 deaths), the case count has tripled since mid-September, and security incidents continue to interfere with response operations, prompting the WHO to upgrade its assessment of the risk of regional Ebola transmission from “high” to “very high” in early October. Several weeks later, the WHO convened an Emergency Committee to review the outbreak and determine if the situation constituted a Public Health Emergency of International Concern (PHEIC). The Emergency Committee ultimately did not recommend declaring a PHEIC; however, they expressed deep concern about the outbreak and called for an intensification of response operations. Nevertheless, Ebola incidence continued to rise.

In light of these worrisome developments, we would like to use this Outbreak Thursday post to highlight the seriousness of the DRC Ebola outbreak and to alert readers to several new calls to action issued this week by academics and practitioners who have been closely following the situation in DRC.

Calls to Action

Yesterday, the New England Journal (NEJM) published two Perspective pieces on Ebola in DRC. The first was written by Tom Inglesby, Director of the Johns Hopkins Center for Health Security, and me. In this piece we detail the potential impacts that could occur if additional resources are not brought to bear to contain the outbreak in DRC, including the likelihood that the virus will spread to neighboring countries and the severe health and economic consequences that would follow in such a scenario. We call for enhanced international contribution to the outbreak, specifically including that the US government should allow CDC field staff to return to areas affected by the outbreak. As we discussed in previous Outbreak Thursday post, contact tracing efforts—which are essential to identifying chains of transmission implementing public health interventions, including vaccination—have been inadequate in the current outbreak. We believe that the US CDC has unmatched experience in responding to Ebola outbreaks in areas where there is community resistance to disease control efforts, and we believe that the return of US CDC personnel is essential to effectively implementing enhanced contact tracing efforts. In our NEJM piece, we also call on the international community to increase operational and financial support for outbreak response operations, including additional contributions to the WHO’s Contingency Fund for Emergencies.

In a the second of this week’s NEJM Perspective pieces on Ebola, authors from the Emory University School of Medicine and the University of Florida College of Medicine point to another unmet need in the response to Ebola in DRC: insufficient plans and tools to protect pregnant women. The authors point out that Ebola virus disease (EVD) threatens the lives of pregnant women and their fetuses. While there is some evidence from previous Ebola outbreaks to suggest that pregnant women may be at increased risk of death from EVD, data have been insufficient to make this determination. This article calls for increased research to fill gaps in knowledge about the risks of EVD during pregnancy as well as identifying mechanisms to protect pregnant women and their fetuses from the virus. The authors further recommend strengthening family planning services in Ebola outbreak settings to prevent unplanned pregnancy and sexual transmission of Ebolavirus infection as well as ending the practice of excluding pregnant women from Ebola vaccine clinical trials.

Finally, the Journal of the American Medical Association (JAMA) published a Viewpoint piece this morning by authors at Georgetown University and the Nuclear Threat Initiative (NTI), which also calls for bringing additional resources to bear in the DRC as well as future outbreaks in conflict zones. This article includes consensus recommendations from a multidisciplinary group of experts convened to deliberate on the ongoing challenges in DRC. In this piece, the authors note that outbreaks of infectious diseases will continue to occur in areas experiencing security and humanitarian conflict, and they call on governments to identify ways of responding to these crises. The recommendations specifically call on the US and the international community to develop plans for experts from the US and elsewhere to safely participate in the DRC Ebola response and craft a framework specifically for responding to future epidemics in conflict zones. They also call for the US and international partners to increase financial support for DRC and to continue to support efforts to strengthen global health security capacities.

Common Themes

There are important common themes across each of these pieces. Outbreaks of Ebola and other high-consequence infectious diseases will continue to occur in areas where there are limited public health capacities and financial resources, particularly those facing conflict or other security challenges. If left unchecked, these outbreaks can pose threats to the health, security, and prosperity of all countries. The international community should develop detailed and concrete plans to respond to these events and devote all of the necessary resources and expertise to containing them before they become epidemics, including provisions for ensuring the safety and security of responders. Though there are risks involved with responding to outbreaks in areas of the world that are experiencing active security conflicts, like we are seeing in North Kivu, there are also serious risks posed by the uncontained spread of these diseases. If Ebola were to spread more broadly, for example, it is difficult to imagine that governments would be hesitant to increase the resources devoted to the response, but these would certainly be orders of magnitude beyond what would be required to contain the outbreak sooner, not to mention the additional morbidity and mortality that would be prevented. The goal of outbreak response is to contain the disease and end transmission before the outbreak becomes an epidemic in order to avert unnecessary loss of life as well as the associated economic, social, and political damage. The resources and expertise exist to stop this outbreak, and we call on the international community, including the US, to find safe and effective ways to commit them to the response.

Photo courtesy of CDC/Cynthia Goldsmith

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.