While understanding of DRC Ebola outbreak unfolds and highlights the continuing challenge of unknowns, responses demonstrate progress

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Pending regulatory, ethics approvals in-country, DRC government, WHO and MSF preparing to offer investigational vaccine to contacts, including healthworkers, frontline teams

Suspected cases all found in single health zone, WHO regional office reports

A month after the current outbreak of Ebola in the Democratic Republic of Congo is believed to have begun, knowledge of where, and among how many people the virus had spread remained challenged by distance, impassable dirt roads, and technology gaps that disrupt electricity and telecommunications, in an area bordered by two countries grappling with conflict, World Health Organization health emergencies director Dr. Peter Salama noted last week. In spite of hard-won knowledge gained in country over the course of seven previous outbreaks of the disease, and internationally during the delayed response to the 2014 West Africa Ebola crisis, they were problems that would continue to serve as an obstacle course in the work ahead to find, diagnose and treat the sick, and end transmissions, he projected: “We cannot underestimate the logistical and practical challenges associated with this response in a very remote and insecure part of the country.” While the border of the Bas-Uele province, where now 37 suspected cases, and four associated deaths have been reported, lies along a border of the Central African Republic, a neighboring province is also bordered by South  Sudan.

But, he added, summing up what may be the greatest advance enabling his agency to respond to this outbreak more effectively than it did to the last, “We’ve also learned never, ever to underestimate the Ebola virus disease.”

That recognition fueled a response that led to laboratory confirmation of one case of the virus within two days of a regional office report of an unexplained cluster of illnesses and deaths associated with vomiting and fever, the arrival of a team of responders to search for more cases within the week, of mobile laboratories in the remote area within the week that followed, and the establishment of an Ebola treatment center. In addition, the DRC government has now requested access to the only investigational vaccine to demonstrate a protective effect against the virus, a necessary first step to securing regulatory and ethics approvals needed to get the vaccine, which has not yet been licensed, to people who have had contact with people sick with the virus and people who, in turn, have had contact with them.

The recognition of the threat posed by the spread of the virus also has accelerated awareness of unknowns surrounding the current outbreak, and to some answers, including a check of a reported outbreak of illnesses with bloody diarrhea in the neighboring province on the South Sudan border, that led the WHO regional office to confirm over the weekend that no evidence of Ebola has been found there.

That is good news said Dr. Dan Lucey, an infectious diseases physician, professor at Georgetown University Medical Center and scholar at the O’Neill Institute for National and Global Health Law, who served two stints at Ebola treatment centers in West Africa during the outbreak there. Not only would the spread of the disease be more difficult still to control across the border of South Sudan, he noted last week, but confirmation that an additional cluster of cases across another remote area would indicate yet more unknowns, including how long the virus had been transmitted among humans in the area, without being noted or tracked. But, he has noted, much more remains unknown, with answers likely to be outpaced by questions. “Each time we have an Ebola outbreak, it is new,” he said. He noted that the number of contacts being tracked leaped last week from 120 to 400, possibly, he said, because of one or more events involving mass exposures. Those would include burials or events in hospital settings.

Dr. Lucey, who criticized the delayed and “terribly suboptimal” responses to the West Africa outbreak by WHO and the international community, welcomed WHO health emergency director Dr. Peter Salama’s words last week, that the agency had learned not to underestimate the disease. He  believes the  responses so far bear that out. “I think they are doing an admirable job, day by day,” he said.

The rest, as answers continue to come, remains a question though. The vaccine, which requires refrigeration, will, when it is approved by local authorities, need to travel long distances, to locations possibly still to be pinpointed. On Thursday Dr. Salama projected that the response needed to track and control the current outbreak will require about $10 million over the months to come. The WHO established a fund for just such a response at the end of the West Africa outbreak, but that fund, Salama said, will be exhausted long before the work ahead is complete.

 

 

One thought on “While understanding of DRC Ebola outbreak unfolds and highlights the continuing challenge of unknowns, responses demonstrate progress

  1. David Fedson

    During the Ebola outbreak in West Africa, local physicians in Sierra Leone treated approximately 100 consecutive patients with an inexpensive combination of a generic statin and a generic angiotensin receptor blocker. Only three patients are known to have died (Int J Infect Dis 2015;36:80-4). There was no support for a clinical trial, and WHO and MSF actively opposed this approach to treatment. Local physicians refused to release information on their findings, and no one has sought to validate them. Although international experts have dismissed this experience, its scientific rationale is rock solid and letters and memoranda exchanged by those involved in treatment suggest it worked. With the re-emergence of Ebola virus disease in the DRC, WHO and international officials should review their opposition to testing this treatment. It might save lives that will otherwise be lost if this outbreak continues to spread.

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