The Current Ebola Outbreak and the U.S. Role: An Explainer
- More than 2,700 cases, including more than 1,800 deaths, have been reported to date in the ongoing Ebola outbreak in the Democratic Republic of Congo (DRC), making it second only to the 2014-2015 West Africa outbreak that saw nearly 29,000 cases and claimed more than 11,300 lives. The outbreak has already lasted more than a year, having been first declared by the DRC Ministry of Health on August 1, 2018. Recently, three imported cases were reported in neighboring Uganda, and there are ongoing concerns about further cross-border spread outside the DRC.
- On July 17, 2019, the WHO Director-General declared the outbreak a “public health emergency of international concern” (PHEIC), citing its duration and recent spread to populated areas (including a case in Goma, a large city bordering Rwanda) where risk of further transmission and potential to cross international borders is high. This was the fourth time the World Health Organization (WHO) had considered such a declaration, after declining to do so three previous times.
- Although the DRC successfully contained previous Ebola outbreaks, multiple factors are contributing to sustained transmission and impeding the response this time including violence and insecurity in the affected areas, entrenched community mistrust of government and external responders, funding constraints, and a complex political and socioeconomic operating environment.
- U.S. engagement has been limited compared to the 2014-2015 West Africa outbreak where the U.S. played a leading role and mobilized an unprecedented amount of funding and personnel. In contrast, the U.S. has chosen to play a more limited role in this outbreak due to a variety of factors, including improvements in the global capacity to respond to Ebola but also because of ongoing security challenges that have led the U.S. to restrict its personnel from working in the outbreak zone.
- The U.S. Agency for International Development (USAID) and the U.S. Centers for Disease Control and Prevention (CDC), along with several other U.S. agencies, have provided technical and financial support to international response efforts in the DRC. In October 2018, USAID announced a Disaster Assistance Response Team (DART), which includes USAID and CDC staff, had been deployed to the DRC.
- A major question for the U.S. government going forward is how much it will expand its technical and financial support for the Ebola response in the DRC, particularly in light of the PHEIC declaration and the lack of progress in interrupting transmission to date.
When did the outbreak begin, and what countries are affected?
The current Ebola outbreak was first declared by the DRC Ministry of Health on August 1, 2018 (see timeline of key events below). Almost all cases of Ebola in this outbreak so far have occurred in the two northeastern DRC provinces of Ituri and North Kivu. It marks the tenth – and by far the largest – in the DRC’s history and the second largest Ebola outbreak ever recorded after the West Africa Ebola outbreak in 2014-2015 that saw 28,616 cases, including 11,310 deaths, in the three most affected countries (Guinea, Liberia, and Sierra Leone).
Cross-border spread is a significant concern. Uganda reported three imported Ebola cases in an area bordering the DRC, with the first case reported on June 11, 2019. With no new cases for more than 42 days, Uganda has been declared Ebola-free for now. WHO says there is a high risk of further spread within the DRC and across borders to Burundi, Rwanda, South Sudan, and Uganda. The recent identification of several cases in the large city of Goma, a regional and international transport hub that directly borders Rwanda, has further highlighted such concerns. Given the risks, neighboring countries have been preparing for possible cases for some time.
|Timeline of Key Events in Current Ebola Outbreak|
|August 1, 2018: Outbreak declared by the DRC Ministry of Health|
|Early August 2018: First U.S. CDC staff deployed to North Kivu province to assist in response efforts|
|August 7-8, 2018: Genetic tests confirm outbreak; vaccination efforts begin|
|August-September 2018: U.S. government pulls back staff from outbreak area due to security concerns|
|October 1, 2018: USAID announces deployment of a Disaster Assistance Response Team (DART) to the DRC|
|October 17, 2018: WHO-convened Emergency Committee recommends that “public health emergency of international concern” (PHEIC) not be declared with regard to the DRC Ebola outbreak|
|November 9, 2018: Ebola case count surpasses largest number from previous DRC outbreaks, making this the largest Ebola outbreak in the DRC’s history|
|Late November 2018: Ebola case count surpasses all but the 2014-2015 West Africa outbreak, making this the second largest Ebola outbreak ever|
|Late December 2018: Voting in the DRC elections postponed in certain Ebola-affected areas, sparking protests|
|February 24, 2019: Ebola treatment center attacked and partially burned down, leading Medicins Sans Frontieres (MSF) to suspend services at the center; another center was attacked three days later, leading MSF to suspend its activities in the area|
|March 30, 2019: Ebola case count in this DRC outbreak surpasses 1,000|
|April 12, 2019: WHO-convened Emergency Committee recommends for a second time that a PHEIC not be declared with regard to the DRC Ebola outbreak|
|April 15, 2019: The DRC Ministry of Health reports over 100,000 people have been vaccinated in this outbreak to date|
|April 19, 2019: WHO epidemiologist from Cameroon killed when a clinic was attacked in Butembo in the DRC|
|June 5, 2019: Ebola case count in this DRC outbreak surpasses 2,000|
|June 11, 2019: Uganda confirmed first imported case of Ebola, with two additional cases reported the next day; no further cases have been reported since|
|June 14, 2019: WHO-convened Emergency Committee recommends for a third time that a PHEIC not be declared with regard to the DRC Ebola outbreak|
|July 14, 2019: The DRC government reports first case in Goma, capital of North Kivu province and a large city of 1-2 million people bordering Rwanda|
|July 17, 2019: WHO-convened Emergency Committee meets for a fourth time; WHO Director-General accepts the Committee’s assessment and declares the DRC Ebola outbreak a PHEIC|
|NOTES: WHO means World Health Organization. The DRC means the Democratic Republic of Congo.|
How many cases and deaths have there been in the DRC?
As of July 31, 2019, the DRC Ministry of Health reports the country has had 2,713 cases (see figure below), of which there were 1,813 deaths. The overall case fatality ratio is high, at 67% as of July 28, 2019.
Health care workers (HCWs), such as nurses and doctors, caring for Ebola patients are at particularly high risk of infection. The Ministry of Health has reported 148 cases and 41 deaths among HCWs over the course of this outbreak so far. In addition, this Ebola outbreak has disproportionately affected children, with about 15 percent of all cases occurring among children under 5 and a higher proportion of the child cases dying from the disease compared with older age groups.
What are the key factors driving the outbreak in the DRC?
Multiple issues make responding to this Ebola outbreak more challenging than any prior outbreaks in the DRC. These include:
- ongoing violence from armed groups that is impeding the response efforts, including violence against Ebola responders, amid long-standing conflict;
- mistrust of the DRC government and outsiders, including Ebola responders, in affected communities;
- disbelief in Ebola (studies find that many in the affected areas believe the Ebola outbreak is not real but rather a hoax perpetrated by the government or other outside parties);
- a shortfall in funding for the Ebola response efforts in the DRC, despite increasing calls from the World Health Organization for donors to fill the gap; and
- transitions in the leadership of the DRC government, including transitions in oversight of the Ebola response.
Role of the U.S.
U.S. engagement in the current outbreak has been limited compared to its role in the 2014-2015 West Africa Ebola outbreak response, where the U.S. played a major leadership role, mobilizing an unprecedented amount of funding, other resources, and personnel to support the Ebola response. Since then, there have been improvements in the global capacity to respond to Ebola, particularly on the part of WHO, and the DRC has had significant experience in addressing prior Ebola outbreaks; both WHO and the DRC took the lead early on in the current outbreak (see KFF brief). In addition, security challenges in the affected areas of the DRC have also prevented U.S. agencies from being more involved. Up to now, the U.S. has provided technical assistance in the DRC and its neighboring countries and provided some funding support while working in conjunction with the national government, United Nations (U.N.) agencies, and other organizations leading the response. U.S. personnel have been restricted from working directly in the hardest hit areas due to security concerns.
The major question for the U.S. right now is how much more support it will provide given the apparent unmet need. Earlier this year, WHO had stated it believed it could work effectively with its existing partners, even without the presence of the U.S. in the affected provinces, to contain the outbreak. More recently, though, WHO officials have sounded much more concerned about the state of the outbreak, with the WHO Director-General saying he is “profoundly worried” and asking for additional support from the U.S. and other donors. WHO’s PHEIC declaration on July 17, 2019, only adds to the perception that the U.S. and other donors could do more to help contain the outbreak.
What U.S. agencies are involved in the response?
The U.S. Agency for International Development (USAID) and U.S. Centers for Disease Control and Prevention (CDC) are the two main agencies contributing to the U.S. government response. USAID’s Office of Foreign Disaster Assistance (OFDA) coordinates U.S. emergency response efforts in the DRC, and in October 2018, the agency announced the deployment of a Disaster Assistance Response Team (DART) to the DRC in response to the outbreak. USAID’s Bureau for Global Health provides operational and personnel support. Several CDC offices, including the Center for Global Health’s Division of Global Health Protection and the National Center for Emerging and Zoonotic Infectious Diseases’ Division of High-Consequence Pathogens and Pathology (NCEZID/DHCPP), provide technical and personnel support. CDC efforts in the DRC are coordinated through its Emergency Operations Center (EOC) in Atlanta, which was activated in June 2019 at its lowest level (level 3).
Other U.S. agencies engaged in Ebola efforts include the National Institutes of Health (NIH) (conducting research on drug and vaccine development, including Ebola treatment trials in the DRC); the U.S. Food and Drug Administration (FDA) (regulating drug and vaccine development); and the Department of State (coordinating the U.S. and international diplomatic response).
Are U.S. government personnel working in the outbreak areas in the DRC?
U.S. personnel have been assisting in the DRC since the outbreak was announced in August 2018, but since late August/early September 2018, no U.S. personnel have been allowed to engage in response activities in the Ebola-affected areas in northeastern DRC. Citing safety concerns due to ongoing violence there, U.S. officials have decided to keep CDC and other U.S. staff away from the front lines of the response. Outside experts have made calls for the U.S. to return CDC staff to affected areas to assist more directly. So far though, there is little indication that the U.S. government will deviate from its current policy, though CDC reports working with the U.S. Department of State to “pre-position CDC staff in Goma to rapidly respond to hotspots where the security situation is permissible.”
Outside of the outbreak zone, U.S. personnel continue to assist. The DART – a “team of disaster and health experts” from USAID and CDC – continues its work in the DRC in response to the outbreak. CDC reports that 43 staff are currently in the DRC. Additionally, other CDC workers have deployed to WHO headquarters and to neighboring countries, such as Uganda, to assist in keeping the virus from crossing borders and to support countries in preparedness and response activities.
How much funding has the U.S. provided?
USAID reports that it has provided more than $136 million toward the Ebola response in the DRC since the outbreak began in August 2018, including an additional $38 million (including $15 million for WHO) that was announced by the agency on July 24. No estimate is available for the amount that CDC has spent on its Ebola response activities. The funding for both USAID and CDC, as well as for other U.S. agencies, in the response is not new funding; rather, it has been drawn from unspent FY 2015 emergency Ebola supplemental appropriations provided by Congress at the time of the West Africa Ebola outbreak. For USAID, leftover funding in the International Disaster Assistance (IDA) account that was designated for “assistance for countries affected by, or at risk of being affected by,” Ebola is being utilized for this purpose, and for CDC, leftover funding that was designated for Ebola international preparedness and response is being utilized.
Global Response Activities
Who leads the response to the outbreak?
The DRC government, including the Ministry of Health, and agencies of the U.N. lead the outbreak response. WHO is the lead U.N. agency for the public health response; other key U.N. actors include the U.N. Office for Coordination of Humanitarian Affairs (OCHA), the U.N. Children’s Fund (UNICEF), the World Food Programme (WFP), and MONUSCO, a multinational peacekeeping force that has been assisting with security. U.N. actors are led by a recently named U.N. Emergency Ebola Response Coordinator.
Other key actors in and supporters of the response include governments of various countries, including the U.S.; multilateral organizations, such as the World Bank and Gavi; international and national non-governmental organizations (NGOs), such as Medicins Sans Frontieres (MSF), International Medical Corps, the Alliance for International Medical Action (ALIMA), and the International Red Cross/Red Crescent; and other partners.
What is the plan for ending the outbreak in the DRC?
Current public health response efforts in the DRC are focused on interrupting chains of Ebola transmission through identifying, isolating, and caring for cases before they transmit the disease further. The goal of the response is to bring the number of cases down “to zero”. Ebola outbreaks are usually declared to be over after 42 days have passed since the last known case (equal to two incubation periods of Ebola virus disease). A national Strategic Response Plan outlines the overall strategy, objectives, and priority activities for responding to the outbreak. There have been three iterations of the plan to date, each covering a specific period of time. The current plan covers planned activities from February through the end of July 2019 and emphasizes strengthening response capacities in priority areas such as: coordination, surveillance and laboratory capabilities, infection prevention and control measures, vaccination, human resources, security, and risk communication among others. The subsequent plan is expected by the end of July. Donors and other partners have urged WHO and the DRC to bolster efforts in key areas in order to make inroads against the outbreak, calling for a “reset” in the response activities of community engagement, vaccination, security, and coordination.
Has the outbreak been declared a global emergency?
On July 17, 2019, the WHO Director-General accepted the recommendation of the Emergency Committee and declared the DRC Ebola outbreak to be a “public health emergency of international concern” (PHEIC). A PHEIC is “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.” In its declaration, WHO released a set of recommended actions for affected countries, neighboring countries, and all states.
This was the fourth time the Emergency Committee had met to discuss a potential PHEIC declaration for Ebola in the DRC; each of the prior three times the Committee recommended not to do so.
What has been the role of vaccination in the current outbreak?
Vaccination has been an important component of the response since it began. This outbreak marks the first time that an effective vaccine is available and being used as a core component of an Ebola response. Authorities are using a “ring vaccination” approach, targeting vaccination of those who have been in contact with a case of Ebola and the contacts of those contacts, along with other groups at high risk such as health care workers. Thus far, over 180,000 individuals have been vaccinated in the DRC (likely preventing hundreds, if not thousands, of Ebola cases already) with an experimental vaccine manufactured by Merck and provided free of charge to WHO and the DRC for the purposes of the response effort. The vaccine is not yet licensed by the FDA (though it is under review) and is being deployed in the DRC on an emergency use basis under a “compassionate use” protocol. Costs for distribution and oversight of vaccinations are shared among Gavi, WHO, other donors, and the DRC government.
In addition to the vaccination efforts in the DRC, neighboring countries are also vaccinating certain people, such as health workers, in areas at risk of seeing or that have seen Ebola cases due to cross-border spread (like Uganda, with approximately 5,000 people vaccinated thus far).
A second experimental Ebola vaccine, manufactured by Johnson & Johnson, is also available, and a WHO expert group has recommended the incorporation of this second vaccine into the response. Even so, the DRC government has so far decided against introducing the second vaccine, citing concerns about the complexities of using two vaccines in the response, particularly the risk of confusion and increasing mistrust among affected communities. This decision could be revisited if the demand for the Merck vaccine in the response begins to outstrip the available supply in the future.
Is there an adequate supply of vaccine?
Over the short term (the next several weeks and months), it appears there are enough doses of the Merck vaccine to meet the demands of the ring vaccination in the response. Over the longer term (6 to 12 months), it is unclear whether the existing and expected supply will be enough, especially if there is a sizeable increase in cases and rising demand for the vaccine. Merck says it has around 243,000 1.0 mL doses available, meaning there is enough vaccine to immunize nearly 500,000 individuals at the 0.5 mL dose being used in the DRC response at the moment. Merck says it plans to produce another 100,000 1.0 mL doses by the end of 2019 and another 450,000 1.0 mL doses in the next 12 months. U.S. CDC Director Redfield expressed concern about whether there was an adequate supply of Ebola vaccine in June 2019. In its July 17, 2019, statement, the WHO Emergency Committee said it “recognizes the shortage of supply” of the Merck vaccine and urged all relevant actors to “immediately take all measures necessary” to increase supply.
Are treatments available for those infected with Ebola?
There are no FDA- or other approved treatments for Ebola, though several promising treatments are under development. Some of these experimental treatments have been provided to Ebola patients in the DRC under a “compassionate use” protocol, and the U.S. National Institutes of Health (NIH) and other partners are conducting a clinical trial of four experimental Ebola treatments in the midst of the current outbreak.
What has the response cost, and how much funding has been provided?
From August 2018 through June 2019 the amount of funding directed to response activities in the DRC included under three iterations of a national Strategic Response Plan has exceeded $200 million. This amount does not include response costs in Uganda, nor preparedness costs in neighboring countries and additional DRC outbreak activities not captured under the plans. The WHO Director-General has called on donors to fully fund the response, and U.N. leadership has said the response will not be successful “without a big scale up in funding.”
Funding amounts provided under each of the plans so far:
- August – October 2018: DRC government data show that the first plan was fully funded, with $44.2 million made available to meet the $43.8 million requested for the August to October 2018 period the plan covered.
- November 2018 – January 2019: U.N. data shows that the second plan was fully funded, with donors (largely the World Bank) providing $61.4 million (including some funds leftover from the first phase of the response) of the $61.3 million requested to cover the period through January 2019.
- February – July 2019: U.N. data shows the current plan has received $109.3 million from February through June 2019, of the $147.9 million requested to cover the period through July 2019. This includes $40 million from the World Bank, with more promised, and $31.2 million from USAID.
Funding needs for the next iteration of the plan are expected to be substantially higher than prior iterations. Some donors, including the World Bank, United Kingdom, and the European Union, have already announced they will be providing additional funding for the response.
As mentioned earlier, USAID reports providing more than $136 million toward the Ebola response in the DRC since the outbreak began in August 2018 (this includes funding channeled through the most recent national Strategic Response Plan and a recently announced $38 million more). No estimate is available for the amount that CDC has spent on its Ebola response activities. All U.S. funding for the current outbreak is drawn from existing funding sources.
Key Issues Going Forward
The recent declaration of the DRC Ebola outbreak as a PHEIC could mark a turning point in the response, though the ultimate effect of the declaration remains to be seen. The expected release of the new national Strategic Response Plan in the DRC in late July 2019 could also signal a shift in approach and a renewed emphasis on the key response activities that donors and partners have been asking for in their push for a “reset.”
Still, the underlying factors driving continued transmission of Ebola in the DRC remain. The security situation shows no sign of abating, and there is even a fear that it may get worse. Mistrust of public health authorities remains a barrier to response efforts. While it is not possible to predict the trajectory of the outbreak, it could take many more months to contain it even under the best of circumstances, and some experts surmise that given the complex set of challenges being faced, the outbreak could take another year, if not longer, to be brought under control.
The major question for the U.S. government going forward is whether or not it will change its approach and engagement in the DRC in light of the PHEIC declaration and the lack of progress in interrupting transmission of the virus so far. This could include additional funding as well as a reconsideration of the decision to prevent U.S. government personnel from working in the outbreak zone to more directly engage in public health activities on the frontlines.