Policy Proposal: EVD outbreak in the DRC
MICHAEL J. SMITH
Health Research and Policy Intern
November 2016- June 2017
Based in New York City Michael is completing a Master's of Public Health at the Icahn School of Medicine at Mount Sinai. He previously has an undergraduate degree in Environmental Biology and has over five years of experience in scientific research and human health. Michael has co-authored a published paper in a national genetics journal and is co-authoring a manuscript to be published in 2017.
The Ebola Virus Disease (EVD) outbreak between 2013 to 2014, the first major outbreak since its discovery in 1976, was the result of a deadly infectious epidemic that emerged from West Africa and led to a formidable outbreak in areas including Guinea, Liberia, Sierra Leone, and Nigeria, killing over 11,000 people. Since the viruses discovery, there have been roughly 25 discrete reports of clustered outbreaks of infections in different countries - all in Africa.
EVD is a zoonotic disease with a high mortality rate (between 50 to 90 percent). The transmission of Ebola between people typically occurs through the exchange blood or bodily fluid exposure, which can put first-line healthcare workers at risk if there is a dearth of infection control or no proper personal protective equipment (PPE) available. Currently, there is no standard treatment for EVD. Fruit bats are considered to be the natural host of Ebola viruses, with occasional outbreaks amongst other species (e.g., gorillas, forest antelope). Ebola is introduced into the human population through close contact with the blood, organs or other bodily fluids of infected animals, either dead or alive.
As of May 22, 2017, the (WHO) announced that there is a total of 37 suspected cases and four deaths of persons with EVD were reported from a remote forested area in the Likati Health Zone, in the Bas-Uélé Province in the North of the Democratic Republic of the Congo (DRC), bordering the Central African Republic. EVD cases have come from five distinct areas in this health zone: Nambwa (twelve cases and three deaths), Muma (four cases and no deaths), Ngayi (sixteen cases and one death), Azande (three cases and no deaths), and Ngabatala (two cases and no deaths). The WHO has reported that no new cases have tested positive for EVD. In a recent report, the WHO stated that “...as of May 21, 2017, 22 samples have tested negative by PCR”. The WHO is also planning to mobilize additional response and testing units to the Buta region of DRC to provide additional support.
Policy I. Improve and bolster weak health systems
Investment in water, sanitation, and hygiene (WASH) is essential to mounting an efficient and expedient Ebola response. We urge the honorable government of the DRC to give immediate attention to improving WASH conditions - especially near schools, economically deprived areas like slums and rural and remote areas. Poor sanitary conditions provide a fertile mechanism for the spread of Ebola through bodily fluids like urine and feces. Suboptimal sanitary conditions are exacerbated by the rainy season, which can increase the spread of cholera outbreaks - further burdening a health system that may be sagging under the burdens of coping with new Ebola cases.
The government of the DRC must invest in appropriate, vigorous and resilient WASH conditions in the already-existing health units - this will improve hand sanitation, cleaning, and disinfection, thereby increasing health workers’ safety and decreasing the likelihood of transmission. Optimal WASH conditions need to be coupled with basic and necessary equipment like chlorine (to minimize contamination and spread), personal protective equipment (PPE) like gloves and goggles, and the necessary training for staff on how to use PPE properly.
Local leadership needs to be mobilized and able to disseminate information regarding suitable WASH conditions. Strong efforts needs to be made on the front lines to convey the necessary information to first responders and medical staff - and follow-up and safety assessment are needed to ensure that staff are continuing to understand safety protocols. Proper training of volunteers and medical staff is paramount; without proper training, no amount of PPE will be effective in protecting first responders.
Policy II. Support and empower the WHO
This policy recommendation is not unique to the government of the DRC, but a full proposal to the global health community as a whole. The WHO received the first report of the Ebola outbreak from Guinea on March 22, 2014 - but did not announce a global emergency until August of 2014, a decision that many non-governmental agencies felt was already tardy, the global media was launched into tumult. The WHO needed over three months to convene health ministers, epidemiologists and international experts to coordinate a regionally focused plan and response.
The reality is that the WHO is financially limited - it has had a steady and declining supply of funds starting in the 1990s. A majority of the budget is already decided before allocation and needs are identified - as a result, the WHO cannot move funds around quickly and freely as needed. Roughly 50 percent cut the WHO has undergone significant, numerous and consistent reductions - namely, the outbreak and crisis response budget - which decreased from nearly $470 million in 2013-14 to $230 million in 2014-15.
The WHO should continue to coordinate international efforts to combat EVD. The international community needs to unite under a common goal of supporting the WHO to guide and facilitate recovery and prevention plans that will provide a sustainable global safety net. Financial commitment from the global community needs to remain steadfast - countries should be contributing a set percentage of total country GDP to the WHO - adjusted for population and economic status. Long-term strategies that are resilient and able to implement disaster risk reduction approaches cost money - limiting the consequences of infectious disease outbreaks should be the primary concern. Emergency response funds needs to be readily available to the WHO for planning education, intervention and response to outbreaks. The WHO will be severely limited if proper funding is not secured.
However, this policy would likely siphon valuable financial resources away from key regions that are already economically depressed. Adding additional financial constraints in regions where health infrastructure is already lacking may prove detrimental and deleterious for emergency response. This policy may not be the best for an immediate response to the Ebola outbreak in the DRC.
Policy III. Create a functional EVD vaccine
Presently, there are no approved drugs or vaccines that can treat or prevent EVD. Current treatment focuses on supportive care - intravenous hydration and respiratory care being the primary methods of treatment. The simple fact remains that the global health community has been aware of the Ebola virus for over 40 years, yet no vaccine has ever been developed. No pharmaceutical company has had the interest or desire to develop such a drug - as the return on investment is minimal. The drug would be deployed in resource-limited settings, and the cost of the drug would have to be very low. The profits from neglected diseases like EVD (and TB, Chagas, Malaria) are small, as the drug would need to be developed, scaled, delivered and administered on a budget, with concerns of profit set aside. At the moment, the DRC just submitted a request for a trial protocol to test an unlicensed vaccine developed by the company Epicentre, in France. A vaccine was developed and tested in 2015 by Merck, but the unconventional administration of the vaccine (ring vaccination) means the results were not as meaningful, and it is only approved for experimental testing.
The expediting and testing of these types of drugs and vaccines is urgent. The streamlining of production must happen by using existing vaccine technologies and that later phase clinical trials should be continued even if definitive data on vaccine efficacy cannot be guaranteed - and trials must be innovative and flexible. Further, once the outbreak has been controlled, stockpiling vaccines for future outbreaks must be considered. Continued assessment of vaccine attributes is needed to inform long-term use and future outbreaks. Quality and accurate surveillance should be in place once vaccines are approved, and vaccine strategies should be initially focused on targeting those at the highest risk. Community engagement efforts should be underway to address any perceived barriers to vaccine acceptance, build trust, foster awareness, and provide education to the community. Transparency is essential in financial transactions that affect pricing as well as decisions regarding who receives limited doses. Officials and ministries of health must examine the creation of an integrated funding strategy that prioritizes public health as the driver over commercial considerations.
However, due to the multiple strains of EVD (Zaire strain, Sudan strain), the vaccine would need to work against several strains. Furthermore, vaccines are often less effective for fast-moving viruses. The vaccine would likely be useful for caregivers and healthcare workers, but would likely do little to quell the immediate burst of an acute outbreak of ebola.
the current outbreak has spread among a handful of poor countries that all have weak health infrastructure. In order to bolster and support the region's most depleted health services, policy option one is the most important. Better safety measures and preventative efforts to stop or contain the spread of disease is paramount. Improving basic sanitation needs of the country will immensely alter the trajectory of an outbreak. Nigeria was first country in West Africa to be Ebola-free, and was able to virtually halt the spread of EVD in a matter weeks. Nigeria achieved this with intense surveillance and public campaigning for things like frequent hand washing.
Ebola has been a known quantity for over 40 years - that fact that no preventive vaccine has been developed in that time is an indictment on the global health community. The best policy option to address past, present and future outbreaks as a supplement to policy two is policy three. A vaccine would be ideal in conjunction with policy one, especially for the present situation in the DRC, where a small pocket of cases are emerging.
Policy option two may be best for the long-term needs of the global community vis-à-vis infectious diseases - but for the immediate outbreak of EVD in the DRC, it would not be the best choice. Funds and resources need to be allocated immediately for emergency response and mobilization efforts. Any policy that delegates financial restrictions for policies that do not immediately address the current outbreak are not advised.