DRC Ebola: "Officials have lost track of where the virus is spreading" UPDATED

UPDATE 10:45 PM ET

On April 12 the World Health Organization published "Preliminary results on the efficacy of rVSV-ZEBOV-GP Ebola vaccine using the ring vaccination strategy in the control of an Ebola outbreak in the Democratic Republic of the Congo: an example of integration of research into epidemic response." (pdf). No time stamp on the report, nor on the news report about the report published at STAT. But given the three comments in response to the STAT report are dated the 13th, I'll venture it was published somewhat late in the day on the 12th. 

END UPDATE

Below are points I've taken from an April 12 Associated Press report headlined  Congo's Ebola outbreak might be declared global  emergency. The report was published just prior to  WHO's decision not to declare a "global health emergency," such meaning a “serious, unusual or unexpected” infectious disease threatening to progress to other countries and requiring “immediate international action.” I don't know and I am not sure I want to know whether such an emergency is the same as a PHEIC (rhymes with "fake") but moving along for now to AP report: 

• ... 75% of new Ebola cases have no obvious link to previous patients, meaning that officials have lost track of where the virus is spreading.

• Emanuele Capobianco, head of health and care at the International Federation of Red Cross and Red Crescent Societies, cited Congolese health ministry statistics showing 40 new cases over two days this week. He called the rate unprecedented in this outbreak.

• The outbreak has been like no other. Capobianco cited lack of trust about Ebola treatment in the community, which had never faced an outbreak of the virus before, and insecurity caused by rebel groups that have hurt aid efforts.

• The outbreak is occurring close to the borders of Uganda and Rwanda, with South Sudan not far away. [One  outbreak region is near Goma, a city of a million people, and which is a major cross-border transportation hub.]

Well, there goes the Ring Vaccination Tactic out the window. You can't vaccinate rings of people around somebody infected with a communicable disease if you don't know who the somebodies are. As the Director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health put it, in what may turn out to be the Quote of the Year: "We have a high percentage of people who are appearing with Ebola after they’ve died."

Sadly for Daniel Drezner, I don't think Dr Inglesby meant to imply Ebola-infected zombies are on the loose. Most probably his tongue just got a little tangled because he was upset about WHO's decision not to declare a global health emergency.   

Even worse upsets may be in store for everyone who placed hope in the use of an experimental Ebola vaccine for ring vaccinations, which you see depend on the vaccine actually working.  

Dr James Wilson, an Associate Research Professor and Director of the Nevada Medical Intelligence Center for the School of Community Health Sciences at the University of Nevada, Reno, co-founder of the Global Health Security Alliance, and arguably the world's top biosurveillance expert, replied to Helen Branswell's April 10 report headlined WHO asks panel to weigh whether Ebola outbreak is global emergency. Dr Wilson wrote in part:

[...]

The second question, which should have been answered transparently months ago is, where is the data on vaccine effectiveness? We aren’t talking about the studies from West Africa but what is going in the DRC. WHO has ignored multiple requests, and that issue is not going away. The Ugandans, Rwandans, and Sudanese [countries bordering DRC] are counting on that vaccine actually working as advertised. And the healthcare systems of Europe and US have an expectation that requires proactive management. Meanwhile we still have reports of healthcare workers dying [from Ebola] without indication of whether they were vaccinated.

The wording of that last remark might reflect Dr Wilson's effort of civility because he surely knows governments and international aid organizations have put much emphasis on using the new vaccine firstly to protect healthcare workers who treat Ebola patients. Indeed, the lead paragraph in a  January ABC News report reads:

South Sudan on Monday began vaccinating its health workers and other front-line responders against Ebola amid fears the deadly disease could spread across the border from the Democratic Republic of the Congo, health officials said.

To return to Dr Wilson's question, it's absolutely vital to learn whether there have been documented failures of the new Ebola vaccine. Such documentation should be readily available if the vaccine had been administered to healthcare workers who'd died from Ebola.

There are a number of reasons why even an effective vaccine could fail; e.g., if it needs to be refrigerated and various batches aren't stored at the proper temperature, or if the vaccinated person doesn't have enough time to build up immunity before exposure to the disease. 

But such reasons point to a problem with what's called in the immunizations business "compassionate" vaccinations. One might question the compassion if aid organizations are using a new vaccine under the most difficult conditions on the rationale that it's better than nothing. Here's an idea of where better than nothing has led in DRC. To return to the AP report:

• Doctors Without Borders is calling for patients to be treated in existing health centers rather than Ebola-specific clinics: “It’s very clear that people do not like or trust the Ebola centers and they are not coming to be treated."

In short, there are two different things going on here. The company that makes the Ebola vaccine and WHO and governments officials tasked with overseeing its use are focused on getting the vaccine administered and tabulating results. As to where this leaves the development of a viable approach to improving Ebola patients' survival rates (currently around 38 percent) -- 

Tell me what kind of mind would think of applying the Ring Vaccination Tactic in a conflict zone, a zone with no prior exposure to Ebola disease, and whose residents distrust foreign devils dressed like invaders from Outer Space coming at them with needles and telling them in a tinny voice emanating from the space suit, 'This is good for you.'

I'll tell you what kind of mind. It's a mind that's not focused on curing people of a disease or alleviating its symptoms. 

Such is the mind of WHO. 

The World Health Organization is focused on working with vaccine manufacturers and governments in order to immunize the entire world population against all diseases that can be vaccinated against. That's who WHO is.  

Whatever the benefits of its focus, WHO is more concerned with the prevention of communicable diseases than with the curing of individuals who fall prey to disease. This means common sense can be the first casualty of the WHO approach to dealing with a lethal infectious disease outbreak.

It is the same with a panel of experts WHO put together. WHO (or the experts) gave the panel a name that translates to the acronym "SAGE." We can assume this was to impress on the yokels in places like DR Congo that WHO takes advice from very wise people. Here's a description of SAGE from April 8 summary of the panel's meeting on April 2-4:

The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.

From the meeting highlights (pdf), we scroll to the last item on the agenda to find mention of the Ebola outbreak -- this at a time when healthcare workers and officials in DR Congo were already tearing their hair and crying, 'My God, we've completely lost control of this outbreak!'

Ebola vaccines

> HO Health Emergencies Response provided an update on the epidemiology of the outbreak in the Democratic Republic of Congo (DRC) and on the status of the Ebola response in North Kivu and particularly noted the important contribution of vaccination in reducing transmission.

> SAGE re-visited the possible vaccination strategies by reviewing epidemiological data and impact modelling. It concluded that ring vaccination currently remains the most effective strategy in this DRC Ebola outbreak.

Geographic targeting should remain as a fall-back strategy. Mass vaccination and ring plus had less favourable overall impact for the doses used in the modelling.

> SAGE reviewed epidemiological data from North Kivu for children below 1 year of age and for lactating women.

Although clinical data on the safety and efficacy of the rVSV-ZEBOV-GP Ebola vaccine for these two specific groups are absent, SAGE considers that the high attack rates and high case fatality rates for these groups, together with the accumulating data on vaccine safety and efficacy for other groups, justify inclusion of children who are above the age of 6 months and of lactating women in the ongoing ring vaccination efforts in North Kivu.

> SAGE strongly urged the implementation of studies to evaluate additional Ebola candidate vaccines, including where possible in pregnant and lactating women and in infants.

If the more high-strung Pundita readers ask, 'Do you mean to tell me they're still on a ring vaccination kick? -- Let us turn to Helen Branswell's report (for STAT) on April 10, the same report that drew a response from James Wilson:

With new case numbers rising at an alarming rate, the World Health Organization said Wednesday it will again look at whether the Ebola outbreak in the Democratic Republic of the Congo should be declared a global health emergency.

The announcement that a panel of outside experts — a so-called emergency committee — will meet Friday to debate the question came on a day when the DRC health ministry was expected to say 18 new Ebola cases had been identified. That marked the highest one-day increase in this epidemic, now in its ninth month.

This will be the second time an emergency committee has been asked to advise WHO Director-General Tedros Adhanom Ghebreyesus on whether this outbreak meets the criteria to be declared a Public Health Emergency of International Concern, known in global health circles as a PHEIC [rhymes with "fake."] The committee met in October and though it described the outbreak as very worrying, it recommended against declaring a PHEIC at that time.

To date the outbreak has not spread to other countries, which is thought to be one of the reasons a PHEIC has not been declared. But it is occurring in what is effectively a conflict zone, a reality that time and again has impeded the response team’s ability to bring transmission to a halt. As of Tuesday there have been 1,186 cases and 751 deaths.

Every time there has been a surge in violence there has been a corresponding sharp rise in cases. But whereas the violence was directed at Congolese soldiers or the United Nations peacekeeping operation in the outbreak area last fall, increasingly the attacks have been directed at the Ebola outbreak response itself.

In late February, Ebola treatment centers at Katwa and Butembo were firebombed by armed assailants, putting both out of commission for a time. Doctors Without Borders, which had been operating those treatment centers, withdrew its staff, saying it could not ensure their safety. Both centers have since reopened and are being operated by the DRC ministry of health and the WHO.

Since those attacks, case numbers have soared, and an outbreak that looked in February like it was coming under control now looks far from it.

Community resistance to the control measures known to stop Ebola transmission remains high in Katwa and Butembo, hotspots that are fueling the outbreak at this point.

Many infected people are refusing to go to treatment centers for care, choosing instead to stay at home. That accelerates spread of the disease because the people who care for these patients will almost inevitably become infected themselves in the process.

There was hope that an experimental Ebola vaccine, made by Merck, would help to contain the outbreak. And WHO officials insist that but for the vaccine, this outbreak would be many times more severe than it already is. More than 97,000 doses of the vaccine have been administered so far in this outbreak.

But failings of the response are undermining the vaccine’s effectiveness. The vaccine is being used in what is called a ring vaccination approach — it is being offered to people who are known contacts of cases and the contacts of the contacts, as well as health workers and other frontline workers. The idea is to prevent spread of the virus by protecting people who are in contact with cases.

For that approach to work, the Ebola response needs to be able to identify as many contacts as possible. But in many cases they have been unable to do the contact tracing work needed to draw up detailed lists; cases have occurred in neighborhoods or villages where it is unsafe for them to work.

As a result, many people who should have been vaccinated have not appeared on the vaccination list.

[...]

Ms. Branswell goes on to report that the prolonged length of the outbreak is raising concerns supplies of the vaccine will run out. But barring that possibility, only howling mobs of Doctors Without Borders workers descending on WHO's headquarters in Geneva might pry SAGE from the Ring Vaccination Tactic in DRC. 

DWB aka Médecins Sans Frontières is very, very upset about WHO's decision not to declare the DRC Ebola outbreak a global health emergency or a PHEIC (rhymes with "fake") or whatever -- although WHO walked right up to the line. In the wake of the decision, DWB/MSF brushed aside WHO's terminology and called the outbreak for what it has become -- maybe not in Geneva but down there on the ground in two provinces in DR Congo: an out-of-control epidemic. And while DWB/MSF stopped short of dismissing the vaccination approach, they issued an impassioned plea for a change in strategy in battling the epidemic, one that was patient- and community-oriented.

But I'll give the last word to Dr Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy. He summed the need for a new direction in combatting Ebola in DRC when he told Helen Branswell, "Doing the same thing over and over again does not appear to be working."

********