On June 4th, the United States House of Representatives’ Subcommittee on Africa, Global Health, Global Human Rights and International Organizations held a hearing titled “Eradicating Ebola: Lessons Learned and Medical Advancements.” This hearing hosted a discussion on the lessons learned from the 2014-2016 Ebola outbreak in West Africa and the ongoing Ebola outbreak in the DRC, including Ebola vaccination activities. Witnesses included Admiral Tim Ziemer, the Acting Assistant Administrator of the US Agency for International Development and Dr. Robert Redfield, the Director of the US Center for Disease Control and Prevention. Outbreak Observatory has written multiple Outbreak Thursday blog posts on the DRC Ebola outbreak response, the most recent of which can be found here. In this post, we will explore the hearing discussions as well as the complicated subtext around the usage of the term “eradicating Ebola” in the hearing title.
Subcommittee Chair Karen Bass and Ranking Member Christopher Smith gave opening statements illustrating the difficult conditions of the current Ebola response in the DRC. At the time of the hearing, 2,020 cases had been reported since the start of the outbreak with 668 of these cases identified in the last 42 days. Concerningly, only 25% of those new cases had known contacts, and 40% were community deaths that occurred outside the health system. The US has provided $87 million dollars in funding to combat the Ebola epidemic in the DRC. Armed conflict and community distrust continues to be the largest ongoing obstacle for the response.
Dr. Robert Redfield expressed concerns about keeping the disease contained to the DRC and ending the outbreak. He stated that while CDC resources were being brought to bear with 184 technical experts currently deployed, a more prolonged response should be expected with a 12-24 month duration. Admiral Tim Ziemer similarly stated that the DRC was an “outbreak in the midst of a complex emergency.” Deep-rooted insecurity and mistrust as well as the presence of approximately 100 armed groups in areas affected complicates the response significantly. His recommendations included bettering coordination with bilateral and multilateral partners such as the WHO Ebola Response Coordinator while continuing with the CDC forward-leaning vaccination strategy. In addition, addressing community engagement and local ownership of the response as well as emphasizing prevention in the Goma-Butembo area and neighboring nations should be a priority going forward. He also recommended addressing “ebola economy” misconceptions, a term commonly used by the people of the DRC to describe the overwhelming arrival of international aid specific to the Ebola outbreak response in direct contrast to the requests for assistance that DRC citizens have been making for years to address concerns related to development and armed conflict. There is a perception that as soon as the outbreak leaves, so will the international assistance, but Admiral Ziemer hopes to address these concerns and misconceptions by increasing the number of projects addressing insecurity and development.
While the Subcommittee members were clearly determined to support the current outbreak in DRC, there was a concern from the Chair and Ranking Member that funding for the DRC may be capped due to the DRC’s Tier 3 status under the 2018 Trafficking in Persons report. This status designates that the DRC is not meeting minimum standards or efforts towards minimum standards for the prevention of human trafficking and therefore has limitations on non-humanitarian, non-trade-related aid from the United States. It is unclear whether or not funding for the Ebola response will qualify for the funding cap at this time. To combat a potential cap, Subcommittee member Karen Bass is asking for support for the Ebola Eradication Act of 2019 to allow USAID to continue funding the Ebola response despite the DRC’s Tier 3 status. This issue could also be prevented if President Trump exercises a waiver authority of the cap under section 110(d)(5)(B) of the Trafficking in Victims Protection Act of 2000 that allows for a cap waiver in order to avoid significant adverse effects on vulnerable populations such as women and children.
Putting “Eradication” into Context
While the Committee on Foreign Affairs met to discuss lessons learned from the Ebola responses and not to discuss eradicating Ebola, as the hearing title alluded to, it is worth reflecting on the use of the word “eradication”. The proper definition of the word is a permanent reduction of the incidence and prevalence of a disease to zero due to deliberate human efforts so that there is no longer a need for ongoing prevention and control efforts. To date the only human disease to be eradicated is smallpox; however, other disease candidates (e.g., polio and dracunculiasis) are the focus of ongoing eradication efforts.
There are no ongoing efforts to eradicate Ebola but should there be? To answer this we have to examine whether Ebola virus would be a good candidate for eradication based on certain criteria that must be considered:
Is the specific biology of the infectious agent favorable for eradication? For example, a good candidate requires humans for its life cycle, has no vertebrate reservoir and does not amplify in the environment. The pathogen cannot escape prevention and intervention efforts via non-human reservoirs and sources.
Is there an effective intervention tool that can be utilized? A good candidate for eradication has a highly effective vaccine that is easily mass-produced and transported in low resource contexts, or has effective environmental interventions available.
Is there a sensitive and specific diagnostic that can work in various capacity settings? The ability to easily identify the disease consistently in all contexts is vital to eradication efforts whether it is done clinically or with a rapid test.
Is the decision to eradicate supported by economic analyses? Eradication is an expensive effort, so it is always important to consider cost-effectiveness of the pursuit over other control strategies.
Is there sufficient social and political support? Governments, funding agencies, disease experts and other stakeholders must all be onboard in order to sustain eradication efforts.
Is operational context and capacity amenable to eradication? Various capacities and conditions such as civil conflict, lab capacities and the presence of sufficient staff are all important to consider before beginning an eradication campaign.
So can Ebola ever be eradicated? While there are very few who think it could be possible due to the highly efficacious rVSV-ZEBOV vaccine, the overwhelming scientific majority is a resounding no due to the presence of multiple animal reservoirs throughout sub-Saharan Africa that let the virus disappear and reappear, evading human interventions.
While it was unclear if the misuse of the term “eradication” was intentional or not by the members of Congress, it is clear that the situation in DRC is dire. The Subcommittee on Africa, Global Health, Global Human Rights and International Organizations is clearly determined to address the epidemic however they can with multiple propositions to maintain funding for the response. However, as Admiral Ziemer aptly said, “there is no silver bullet to end this outbreak,” so it is expected that as long as the instability and community distrust continues, the outbreak will continue as well.
Photo courtesy of Pixabay (https://pixabay.com/photos/united-states-capitol-politics-1675540/)
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.