World Health Organization declares Ebola outbreak an international emergency

The World Health Organization (WHO) today declared that the Ebola outbreak in the Democratic Republic of the Congo (DRC), which surfaced in August 2018, is an international emergency. The declaration raises the outbreak’s visibility and public health officials hope it will galvanize the international community to fight the spread of the frequently fatal disease.

“It is time for the world to take notice and redouble our effort,” WHO Director-General Tedros Adhanom Ghebreyesus said in a statement. “We all owe it to [current] responders … to shoulder more of the burden.”

As of today, Ebola has infected more than 2500 people in the DRC during the new outbreak, killing more than 1650. By calling the current situation a Public Health Emergency of International Concern (PHEIC), WHO in Geneva, Switzerland, has placed it in a rare category that includes the 2009 flu pandemic, the Zika epidemic of 2016, and the 2-year Ebola epidemic that killed more than 11,000 people in West Africa before it ended in 2016.

The declaration does not legally compel member states to do anything. “But it sounds a global alert,” says Lawrence Gostin, a global health lawyer at Georgetown University in Washington, D.C. During the West African epidemic, for instance, the U.S. Congress supplied $5.4 billion in the months after WHO’s emergency declaration.

Even as they declared the emergency, WHO officials attempted to tamp down reactions they said could harm both the DRC’s economy and efforts to stop the outbreak. “This is still a regional emergency and [in] no way a global threat,” said Robert Steffen, chair of the emergency committee that recommended the PHEIC designation and an epidemiologist at the University of Zurich in Switzerland, during a press teleconference today. He added in a written statement: “It is … crucial that states do not use the PHEIC as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region.”

The DRC’s minister of health, Oly Ilunga Kalenga, issued a statement accepting the declaration but expressing concern about its motives and the potential impact on his country. “The Ministry hopes that this decision is not the result of the many pressures from different stakeholder groups who wanted to use this statement as an opportunity to raise funds for humanitarian actors,” Kalenga wrote. He said such funds could come “despite potentially harmful and unpredictable consequences for the affected communities that depend greatly on cross-border trade for their survival.”

Steffen’s committee previously declined three times, most recently last month, to recommend that WHO declare the outbreak an international emergency. What changed, he said today, was the 14 July diagnosis of a case of Ebola in the large, internationally connected city of Goma, DRC, from which 15,000 people cross the border into Rwanda each day; the murders last weekend of two health workers in the city that is now the Ebola epicenter of the DRC; a recurrence of intense transmission in that same city, Beni, meaning the disease now has a geographical reach of 500 kilometers; and the failure, after 11 months, to contain the outbreak.

Funding is also at issue. In June, WHO announced its funding to fight the outbreak fell $54 million short; today, accepting the emergency committee’s recommendation, Tedros said the funds needed to stop the virus “will run to the hundreds of millions. Unless the international community steps up and funds the response now, we will be paying for this outbreak for a long time to come.” (A written report from today’s meeting added: “The global community has not contributed sustainable and adequate technical assistance, human or financial resources for outbreak response.”)

When the first known Ebola case in Goma was diagnosed this week, concern spiked about international spread. In addition to being a metropolis of nearly 2 million people where Ebola may spread quickly and be difficult to trace, Goma has an international airport. Separately today, the government of Uganda, in conjunction with WHO, issued a statement describing the case of a fish trader who died of Ebola on 15 July; she had traveled from the DRC to Uganda on 11 July before returning to the DRC.

“Although there is no evidence yet of local transmission in either Goma or Uganda, these two events represent a concerning geographical expansion of the virus,” Tedros said. The risk of spread in DRC, [and] in the region, remains very high. And the risk of spread outside the region remains low.”

Last month, the outbreak’s first known Ebola fatalities outside the DRC were reported in a 5-year-old boy and his grandmother. The two had traveled from the DRC to Uganda after attending the funeral of a relative who died from Ebola.

Health officials are also worried about the safety of those battling the outbreak. Since January, WHO has recorded 198 attacks on health facilities and health workers in the DRC, killing seven, including two workers who were murdered during the night of 13–14 July in their home in Beni. The two northeastern DRC provinces that have experienced the outbreak are also plagued by poor infrastructure, political violence, and deep community distrust of health authorities.

Josie Golding, epidemics lead at the Wellcome Trust in London, applauded the declaration of the PHEIC. “There is a grave risk of a major increase in numbers or spread to new locations. … This is perhaps the most complicated epidemic the world has ever had to face, yet still the response in the DRC remains overstretched and underfunded.”

Gostin called the declaration “long overdue. Until now the world has turned a blind eye to this epidemic. WHO has been soldiering on alone, bravely alone. And it’s beyond WHO’s capacity to deal with all of this violence and community distrust.”

PHEICs are governed by the International Health Regulations, a global agreement negotiated in the wake of the 2003 severe acute respiratory syndrome outbreak. The regulations, in force since 2007, stipulate that a PHEIC should be declared when an “extraordinary” situation “constitute[s] a public health risk to other States through the international spread of disease” and “potentially require[s] a coordinated international response.”

WHO officials also today addressed the thorny conflict over whether a second, experimental Ebola vaccine, in addition to a Merck vaccine that has already been given to 161,000 people in the DRC, should be deployed there now. Officials worry that Merck’s stockpile—although it is being stretched by reducing the dose of the vaccine being given to each recipient—will be depleted before the outbreak ends. But on 11 July, Kalenga gave a firm “no,” rejecting the use of any new experimental vaccine in the country because of unproven effectiveness and the potential for public confusion. (A Johnson and Johnson [J&J] vaccine that has been shown to be safe in healthy volunteers is waiting in the wings and its use has been advocated for by several infectious disease experts.)

But today, Michael Ryan, executive director of WHO’s Health Emergencies Programme, said the organization still supports introducing the J&J vaccine if it can win “appropriate national approval.” “The Ministry has expressed concern about introducing a second vaccine … mainly around the issue of confusion in the local population. We are working through those issues about where and when the vaccine could be used,” Ryan said.

David Heymann, an infectious disease epidemiologist at the London School of Hygiene & Tropical Medicine, and formerly WHO’s assistant director-general for health security and environment, said today’s emergency declaration may have set a precedent. “The Emergency Committee appears to have interpreted the need for funding as one of the reasons a PHEIC was called—this has not been done in the past.”