Portal de Periódicos da CAPES

Ebola in the Democratic Republic of the Congo: time to sound a global alert?

2019; Elsevier BV; Volume: 393; Issue: 10172 Linguagem: Inglês

10.1016/s0140-6736(19)30243-0

1474-547X

Lawrence O. Gostin, Alexandra Phelan, Alex Godwin Coutinho, Mark Eccleston-Turner, Ngozi Erondu, Oyebanji Filani, Tom Inglesby, Rebecca Katz, Allan Maleche, Jennifer B. Nuzzo, Oyewale Tomori, Matthew M. Kavanagh,

Global Public Health Policies and Epidemiology

The epidemic of Ebola virus disease in the Democratic Republic of the Congo (DRC) is the second largest in history after the 2014 west African epidemic. A storm of detrimental factors complicates this event: armed conflict, political instability, and mass displacement. WHO, the DRC Government, and non-governmental organisation (NGO) partners have shown remarkable leadership but are badly stretched. The outbreak remains far from controlled, risking a long-term epidemic with regional, perhaps global, impacts. Faced with an evolving complex humanitarian crisis, and recent elections complete, WHO Director-General Tedros Adhanom Ghebreyesus should reconvene the Emergency Committee (EC) and consider declaring a Public Health Emergency of International Concern (PHEIC). The first EC report on Oct 17, 2018, called for "intensified" action, fearing "significant deterioration".1WHOStatement on the October 2018 meeting of the IHR Emergency Committee on the Ebola virus disease outbreak in the Democratic Republic of the Congo.http://www.who.int/news-room/detail/17-10-2018-statement-on-the-meeting-of-the-ihr-emergency-committee-on-the-ebola-outbreak-in-drcDate: Oct 17, 2018Date accessed: January 25, 2019Google Scholar The EC's fears have been prescient. Cases of Ebola virus disease have more than tripled, with an expanded geographical footprint into 18 health zones.2WHOEbola virus disease—Democratic Republic of the Congo External Situation Report 25: update.https://apps.who.int/iris/bitstream/handle/10665/279811/SITREP_EVD_DRC_20190123-eng.pdfDate: Jan 23, 2019Date accessed: January 29, 2019Google Scholar Governments, including the USA, have withdrawn personnel, fearing for their safety.3Gostin LO Kavanagh MM Cameron E Ebola and war in the Democratic Republic of Congo: avoiding failure and thinking ahead.JAMA. 2019; 321: 243-244Crossref PubMed Scopus (15) Google Scholar Effective mitigation requires case identification. Yet less than 20% of new Ebola cases have been on known contact lists.4Nuzzo JB Inglesby TB Ramping up the response to Ebola.N Engl J Med. 2018; 379: 2490-2491Crossref PubMed Scopus (11) Google Scholar This situation undercuts vital interventions, such as contact investigations, isolation, and safe burials. WHO might have to shift from ring vaccination to vaccination based on geographical location, but doing so effectively will require far more doses; limited vaccine supplies, therefore, are concerning.5Kelland K As Ebola threatens mega-cities, vaccine stockpile needs grow. Reuters.https://www.reuters.com/article/us-health-ebola-stockpile/as-ebola-threatens-mega-cities-vaccine-stockpile-needs-grow-idUSKCN1OJ21BDate: Dec 20, 2018Date accessed: January 18, 2019Google Scholar The risk of cross-border spread of Ebola virus disease to Uganda, Rwanda, and South Sudan is high.2WHOEbola virus disease—Democratic Republic of the Congo External Situation Report 25: update.https://apps.who.int/iris/bitstream/handle/10665/279811/SITREP_EVD_DRC_20190123-eng.pdfDate: Jan 23, 2019Date accessed: January 29, 2019Google Scholar Tens of thousands of Congolese cross borders daily to trade, to visit family, or for funerals. Roads to Kigali and Kampala are well travelled and could facilitate Ebola transfer to large population centres. Uganda and Rwanda have fairly strong surveillance systems and are preparing for cross-border spread. Uganda vaccinated essential health workers and is reportedly screening all travellers at Entebbe airport.6The Observer (Kampala)WHO orders mandatory Ebola screening at Entebbe airport.The Observer (Kampala). Jan 14, 2019; https://allafrica.com/stories/201901140542.htmlDate accessed: January 16, 2019Google Scholar Yet cases could be missed at the border. South Sudan, meanwhile, is among the world's most fragile states. A widening epidemic of Ebola virus disease could destabilise the region and disrupt the tenuous peace in South Sudan, where violence continues and famine is predicted.7Kuol L Why South Sudan faces collapse if peace pact fails—again.The Conversation. Nov 8, 2018; https://theconversation.com/why-south-sudan-faces-collapse-if-peace-pact-fails-again-106188Date accessed: January 25, 2019Google Scholar In the past 6 months, 300 000 DRC refugees have crossed into Uganda, adding to a refugee population of about 1 million.8UNHCROperational PortalDRC situation. Data as of 31 December 2018.https://data2.unhcr.org/en/situations/drcDate accessed: January 25, 2019Google Scholar The west African epidemic of Ebola virus disease in 2014–16 reduced regional economies by US$2·8 billion.9World Bank2014–2015 West Africa Ebola crisis: impact update.http://www.worldbank.org/en/topic/macroeconomics/publication/2014-2015-west-africa-ebola-crisis-impact-updateDate: 2016Date accessed: January 14, 2019Google Scholar Similar impact in DRC and neighbouring countries could devastate fragile economies. The legal criteria for a PHEIC have been met. The International Health Regulations (2005) (IHR) empower the WHO Director-General to declare a PHEIC. A PHEIC is an extraordinary event with public health risk to other countries that requires a coordinated international response.10WHOInternational Health Regulations 2005.third edition. World Health Organization, Geneva2005Google Scholar IHR criteria include public health impact, novelty and scale, and movement of persons.10WHOInternational Health Regulations 2005.third edition. World Health Organization, Geneva2005Google Scholar The WHO Director-General must also consider health risks, potential international spread, and EC guidance, among other factors. The report of the EC in October, 2018, expressed concern about armed conflict and new cases without known links, but advised against a PHEIC "at this time".1WHOStatement on the October 2018 meeting of the IHR Emergency Committee on the Ebola virus disease outbreak in the Democratic Republic of the Congo.http://www.who.int/news-room/detail/17-10-2018-statement-on-the-meeting-of-the-ihr-emergency-committee-on-the-ebola-outbreak-in-drcDate: Oct 17, 2018Date accessed: January 25, 2019Google Scholar Unlike past statements, the EC did not say "the conditions for a PHEIC have not been met". The DRC epidemic meets PHEIC criteria and has for some time. The IHR empower a PHEIC for "potential" cross-border transmission, without waiting until international spread has occurred. The Ebola epidemic in DRC is unfolding amid regional conflict, as attacks on medical staff coincide with subsequent spikes in cases.11Morrison JS Devermont J North Kivu's Ebola outbreak at day 90. Center for Strategic and International Studies.https://www.csis.org/analysis/north-kivus-ebola-outbreak-day-90-what-be-doneDate: Nov 1, 2018Date accessed: January 30, 2019Google Scholar We call upon the WHO Director-General to reconvene the EC to review the grounds for a PHEIC declaration. He should invite states, the UN, and NGOs to attend and submit evidence.10WHOInternational Health Regulations 2005.third edition. World Health Organization, Geneva2005Google Scholar The United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO), UNHCR, the UN Refugee Agency, and civil society could provide critical information. The EC should recommend proactive measures on health, diplomacy, security, and community engagement. Concrete recommendations could specify the level and kind of resources needed and composition of security and diplomatic assets. A PHEIC is a clarion call to galvanise high-level political, financial, and technical support. A PHEIC would provide a clear signal from the world's global health body that UN leadership is urgent. A PHEIC also empowers the WHO Director-General to make temporary, non-binding recommendations that have normative force.10WHOInternational Health Regulations 2005.third edition. World Health Organization, Geneva2005Google Scholar The IHR do not specify any surge in authority or financing when declaring a PHEIC. In the past, states did not heed WHO warnings that travel and trade restrictions are harmful. During the west African Ebola epidemic, 58 states restricted travel from affected areas, and during the 2009 influenza A H1N1 pandemic, states imposed trade and travel restrictions.12Tejpar A Hoffman SJ Canada's violation of international law during the 2014–16 Ebola outbreak.Canadian Yearbook Int Law. 2017; 54: 366-368Crossref Scopus (7) Google Scholar, 13Nuzzo JB Cicero AJ Waldhorn R Inglesby TV Travel bans will increase the damage wrought by Ebola.Biosecur Bioterror. 2014; 12: 306-309Crossref PubMed Scopus (12) Google Scholar, 14Gostin LO DeBartolo MC Katz R The global health law trilogy: towards a safer, healthier, and fairer world.Lancet. 2017; 390: 1918-1926Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar Trade or travel barriers in the DRC would have devastating impacts. WHO, with UN support, should take active steps to prevent unlawful and harmful restrictions. In 2009, WHO and the World Trade Organization (WTO) criticised governments that took non-evidence-based actions; going forward, WHO and WTO could publicly name non-compliant countries. Governments should also agree to dispute resolution, including binding IHR arbitration.10WHOInternational Health Regulations 2005.third edition. World Health Organization, Geneva2005Google Scholar If a PHEIC escalated conflict by raising the profile of the international response, it would be deeply concerning. Recent elections in DRC were clouded by concerns about vote-rigging, unsettling lines of power and legitimacy. Armed groups have used violence to generate chaos. A PHEIC could increase incentives to target Ebola responders to gain leverage. As in South Sudan, armed groups could manipulate aid for non-humanitarian purposes.15Yayboke E Accessing South Sudan: humanitarian aid in a time of crisis.CSIS Briefs. Nov 27, 2018; https://www.csis.org/analysis/accessing-south-sudan-humanitarian-aid-time-crisisDate accessed: January 25, 2019Google Scholar Like any complex multilateral negotiation, cultural competence and smart diplomacy are required. Outsiders are unlikely to be privy to all on-the-ground realities and risks. The IHR were designed to respond to a health emergency like the DRC Ebola epidemic. We urge the WHO Director-General to reconvene the EC and re-assess the declaration of a PHEIC. The UN and governments should increase support for WHO and partners. If the IHR fails, or worse, increases political instability, it will require urgent reform. State non-compliance should not obscure the value of the IHR in establishing norms of rapid identification, notification, and response. The IHR require states to develop health-system capacities, assessed by WHO's Joint External Evaluation. IHR reform should focus on technical and financial assistance for national health capacities. A PHEIC should trigger surge capacity in relation to authority and finances, with effective mechanisms to gain state compliance. WHO has shown leadership and operational endurance, working tirelessly to combat the DRC Ebola epidemic. But WHO and partners cannot succeed alone. We live at a political moment when international solutions to collective threats are increasingly hard to achieve. But WHO and the UN system will be called upon with ever-greater frequency in the future to manage complex humanitarian crises. We must plan for a future in which political violence and instability become the new abnormal. AGC, NE, OF, TI, RK, AM, JBN, OT, and MK declare no competing interests. LG is Director of the WHO Collaborating Center on National and Global Health Law, and is on the IHR Roster of Experts. AP previously worked as a consultant to the WHO on unrelated matters in 2017 and earlier. ME-T worked as a paid consultant to the WHO Working Group on Influenza Vaccine Supply Hubs during 2018.