The current Ebola outbreak in the Democratic Republic of Congo (DRC) is the second largest ever recorded. As we addressed in several previous Outbreak Thursday posts, controlling the spread of disease has proven to be quite difficult, even with the availability of an investigational vaccine that has been administered to more than 60,000 individuals. Armed conflict, public distrust, and political unrest surrounding recent national elections have all added to the challenges of interrupting transmission, and these factors have directly contributed to the inability to implement adequate contact tracing programs, a critical tool for outbreak response. As the total number of cases surges towards 800 (791 as of February 6), a group of international experts led by Georgetown University—including the Center for Health Security’s Director, Tom Inglesby, and myself—have written a commentary, published this week in The Lancet, that calls on the WHO to once again consider whether the Ebola situation in the DRC constitutes a Public Health Emergency of International Concern (PHEIC).

Following a surge in the incidence of new cases in early October 2018, the WHO convened an Emergency Committee to determine if the outbreak should be declared a PHEIC. At the time, the committee opted not to declare a PHEIC, but rather, “emphasized that the response activities need to be intensified,” otherwise the situation could “deteriorate significantly.” It was a decision that was criticized by some.

Since the WHO Emergency Committee last met in October, the outbreak has continued to grow, now the second largest on record. A redoubling of efforts to control the spread of Ebola in Beni, a key epicenter of the outbreak, has resulted in a decline in the incidence of new cases in recent weeks, even in the face of ongoing security-related challenges. But the overall number of Ebola cases has more than tripled and the geographic footprint of the outbreak has expanded since October, which effectively diluted the impact of limited available resources. Violence in the region has escalated, prompting international NGOs and some governments to withdraw personnel. The situation on the ground is dangerous, with ongoing active armed conflict, public distrust, and geopolitical volatility. In fact, violence and misinformation associated with a contentious presidential election prompted the national government to cut off internet access nationwide leading up to the election itself as well as the publication of preliminary results. Additionally, the risk of cross-border spread of Ebola virus disease to neighboring countries—including Uganda, Rwanda, and South Sudan—remains elevated, considering the thousands of travelers in the region who cross borders daily to engage in trade, visit family, or for other purposes.

In the Lancet commentary, we review the criteria for declaring a PHEIC, which are established by the International Health Regulations (IHRs). The WHO Director General, with input from an Expert Committee, may declare a PHEIC based on an event’s public health impact, novelty and scale, potential for international spread, and need for coordinated international response. The IHRs permit the declaration of a PHEIC for events that have the potential for cross-border spread and do not require waiting until such spread has occurred. Considering the location of the outbreak on the borders of multiple countries, the volume of travel across these borders, and the limited ability to identify and monitor potentially exposed individuals, we argue that Ebola in DRC “meets PHEIC criteria and has for some time.” Though the WHO Emergency Committee recommended against a PHEIC declaration at the first meeting, it did not explicitly address in its statement whether or not the outbreak, in fact, actually met the criteria for such a designation. Regardless of whether the PHEIC declaration was warranted in October, the situation certainly appears to be more urgent now.

Much of the value of a PHEIC declaration lies in its role as an international call to action, highlighting the need for high-level political, financial, and technical support for response activities. A PHEIC declaration is also a normative act—one that reminds the world about the IHRs’ legal requirements for countries to develop and maintain the capacities to prevent, detect, and respond to health emergencies, including PHEICs. Failing to declare a PHEIC when the conditions are met would undermine the authority of the IHRs to compel countries to take national actions for the protection of global health security. While there are concerns that a PHEIC declaration could lead other countries to implement non-evidence-based actions, such as restricting travel and trade, that would have negative effects on response activities as well as political, economic, and social climates in the affected country or countries, mechanisms do exist for discouraging countries from taking such measures. For example, the WHO and World Trade Organization (WTO) could publicly name non-compliant countries, which could factor into broader geopolitical standing for those countries.

We believe that the WHO should reconvene the Emergency Committee under the IHRs to determine if the situation in the DRC now constitutes a PHEIC. A PHEIC declaration could increase international attention to the Ebola outbreak and put pressure on other countries to increase their operational and technical support for response activities. As we noted previously, containing the DRC Ebola outbreak will require an expansion of existing efforts to identify all Ebola cases and their contacts in order to successfully interrupt all chains of transmission. Thus far, only a small minority (fewer than 20%) of identified Ebola cases were known to be at-risk contacts prior to being diagnosed, indicating the significant struggles responders have faced in implementing effective contact tracing efforts. Additionally, the outbreak has grown considerably since the first Emergency Committee meeting, nearly tripling in size to become the second largest ever recorded. Response operations, contact tracing in particular, have been compromised by the challenging security situation throughout the outbreak; however, the recent decrease in Ebola incidence in Beni suggests that further gains can be made with adequate resources and support. The longer we wait to allocate additional resources, the greater the risk that the outbreak will spread to neighboring countries, which would place additional populations at risk, pose additional coordination challenges, and further dilute available personnel, funding, supplies, and equipment.

Photo is a scanning electron microscope (SEM) image of several Ebola virions budding from a mammalian kidney cell; courtesy of the National Institute of Allergy and Infectious Disease (NIAID).

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.