A few weeks ago, the Director of the CDC made comments to the mainstream media raising the spectre of endemic Ebola virus disease, or an ongoing, permanent infection in the Democratic Republic of the Congo (DRC).

I do think this is one of the challenges we’ll have to see, whether we’re able to contain, control and end the current outbreak with the current security situation, or do we move into the idea that this becomes more of an endemic Ebola outbreak in this region, which we’ve never really confronted,”
-Washington Post

Endemic Ebola virus disease is a worrying thing to concede. It’s a horrifying thing to contemplate. A virus that regularly and relatively quickly kills over half of those whom it infects is not one we should walk away from, anywhere in the world. There is no option where giving up on trying to overcome an Ebola virus disease (EVD) outbreak is good sense, good economics or good for global security and health.

At around the same number of reporting days (around 105 when the Director commented), the huge multi-country Ebola virus epidemic engulfing West Africa had engaged three countries and reported confirmed cases were averaging about 6 to 13 per day. It scaled up to over 100 cases per day with an exponential rise of new cases. Currently, the DRC outbreak is regularly reporting 2 to 7 cases per day.

What’s different about the Congo outbreak?

The current outbreak in North Kivu Province does differ from the West Africa epidemic in a few ways. Encouragingly, the Ituri Province outbreak seems to have been brought under control.

Ongoing and unpredictable outbreaks of violence have rendered some areas as no-go or red zones and created a very complicated situation for health workers trying to track and vaccinate contacts. Violence had been a recurring issue and has come extremely close to health workers. Some of this violence has already occurred where EVD cases are located, causing interruptions to contact tracing and vaccination efforts. Ironically, at least one instance was due to an infected person moving away from a region relatively free of conflict and into a red zone, where treatment is difficult to administer, triggering new cases.

Cases in the DRC have also stayed below double digits per day. They have ticked up over October and during November rather than down but remain in a scattered collection of health zones, within a single country. Border checks have so far kept the virus from moving into one of the closely neighbouring countries. As far as we know.

We have an EVD-preventing vaccine which has been shown to be effective. This vaccine didn’t exist at this stage of the West Africa outbreak. But a vaccine alone can’t halt an outbreak of EVD. Despite assurances that it was only a small problem, vaccine resistance seems to have become an issue.

Vaccine use was seeing good acceptance (95-98%). However, this was briefly but repeatedly impacted by violence, in one instance dropping contact vaccination rates to 60-76%. Community resistance remains, as it did in West Africa. There was limited capacity in place to prevent the rapid uptick in cases occurring in West Africa at this stage, but there’s been more thought put into the DRC outbreak, despite it smouldering for months before official reporting started. The ever-vigilant MSF have been onsite along with a reinvested World Health Organization (WHO). New drugs are being trialled, and there are new patient management approaches like that thanks to the ALIMA biosecure emergency care units (CUBE).

A strange pattern has also emerged in the DRC’s latest outbreak involving the detection of a relatively high proportion of children infected with the Ebola virus. This is likely to teach us something new.

It feels, at least until recently, like we haven’t seen much on the ground reporting from the hot-zone. Stories that convey those personal stories and behind-the-scenes nuggets seem to have been slow in coming. There have been no recent widespread public calls for international help, volunteers, money or supplies although it seems these are not needed; another stark contrast to the West Africa epidemic. Everything seems more under control than we saw in West Africa. Apart from the considerable risks associated with violence.

The WHO has certainly not talked about ceding the field to this virus yet. MSF is stoically doing the job at hand as usual. The DRC Ministry of Health has been upfront about the challenges but haven’t started talking about plans for an endemic Ebola nation. 

So what does the CDC Director know that the rest of us don’t? During the West African, Dr Tom Frieden was directing the CDC. He was subsequently taken to task for comments including “..we’ll stop this in its tracks in the U.S.” There were cases after an infected traveller was hospitalised, yet further spread was indeed quickly stopped. Frieden came back from visits well informed and laid out the lack of control. Publicly at least, Frieden’s mantra was one of containment and resolution, not waving of a white flag. 

Positive messaging from those who have experience

The CDC Director’s message quickly seemed out of step with other organisations heavily involved in saving lives, containing flare-ups and preventing the EVD outbreak from spreading.

What have EVD experts recently said about the current outbreak?

“The Ebola response is a priority of the U.S. government” Tim Ziemer, a senior official at USAID. Dr Peter Salama, who heads the WHO’s emergency response program suggested: “it will take at least another six months to contain the outbreak in DRC.” Dr Tedros Adhanom Ghebreyesus, the WHO DG, stated that “The insecurity is a virus. And there is another virus, Ebola. Managing two viruses at the same time is tough, but at the same time, we’re having an impact.” Médecins Sans Frontières (MSF), who neither sugar-coat situations or create unnecessary fear, exuded their usual get-to-work attitude in a November Crisis Update saying, “We remain ready to support the authorities of these – and other – neighbouring countries in the implementation of their response to the Ebola outbreak in DRC.” Pierre Rollins, who has studied Ebola for three decades, had earlier said he thought “it could potentially be brought under control within a month or two, as authorities expand their tracing of new patients’ contacts“. Rear Admiral Tim Ziemer, who is currently serving as the U.S. Agency for International Development’s acting assistant administrator in the Bureau for Democracy, Conflict, and Humanitarian Assistance was very clear when he said “We can’t be blind and turn our back on this current challenge, as turning our back on it doesn’t mean it’s going to go away.” Mike Ryan, Assistant Director-General of Emergency Preparedness and Response at the WHO was also balanced in his comments: “Fears of this thing becoming endemic are real, and rational, but we also need to see that as a worst-case scenario”, “We still have plenty of opportunities to put this virus back in the box, we just need to get behind the people risking their lives on the front line and push hard for the next three to six weeks. It’s going to be a long march, but I don’t think we should be raising the white flag just yet.”

The WHO noted in its latest Disease Outbreak News (15NOV2018) that “New measures to overcome obstacles in responding to the Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo are having a positive impact. The Ministry of Health (MoH), WHO and partners continue to be confident that, despite challenges, the outbreak can be contained.”

Messaging with a realistic yet positive tone

These are all messages that don’t shy away from the hard, complex and dangerous work ahead. Brilliant. It is going to be a grind to eradicate this outbreak, but gains could be obliterated if violence targets the responders specifically, or just continues to interrupt their work until it becomes too hard to continue. Targeted or extended and ongoing violence would change the response. Targeted violence isn’t happening right now, and even if it were, I’d argue that it wasn’t a reason to consider giving up. The comments above don’t concede that the virus is on the verge of defeating us. They realistically recognise that work from all parties will be needed to contain the outbreak. That is an important distinction to make. These comments also provide some rare hope. And they point to the need for further innovation, intervention and perhaps a call to re-visit or reinforce peace-keeping efforts and strategies.

Why so negative?

It seemed a very strangely timed message from the current CDC Director, especially when made about an outbreak that, compared to the EVD epidemic in West Africa, was less out of control. There was talk of the virus becoming entrenched and endemic back in 2014 also. That language was different though; more a hint of what could happen should support and efforts falter or commitment wane.

In the end, because of a massive multi-national commitment, especially from among the people living in those areas, Ebola virus was contained. To be clear, it was contained in humans, but these viruses are never going to be eradicated. We have some evidence to support the enzootic nature of this filovirus, with bats infected by Ebola virus that live across a large belt encompassing western and central Africa.

Perhaps a comment from former “Ebola czar” Ron Klain sums the flavour of the Director’s comment up best: “It’s not the same kind of leadership from the U.S. in a global health crisis that we have seen previously in Democratic and Republican administrations.” No, it certainly appears that it isn’t.

I hope we don’t have to exist for long with a U.S. that prepares for defeat before it exhausts its efforts to innovate for success.

References…

1. CDC director warns that Congo’s Ebola outbreak may not be containable
   https://www.washingtonpost.com/health/2018/11/05/cdc-director-warns-that-congos-ebola-outbreak-may-not-be-containable/?noredirect=on&utm_term=.4b176d725c88

Updates

1. 21-2NOV2018. Editing and addition of a new quote.

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