Seeing a crèche set up next to an Ebola Treatment Centre in the Democratic Republic of the Congo (DRC) is about as heart-breaking as it comes. Because it’s hard not to dwell on the fact that many of the children dropped off there while their parents receive medical treatment are essentially orphans-in-the-making. But, while such facilities are a necessary development in the response to this public health crisis, what is perhaps even more tragic is that they are needed; that one year into this epidemic we are still no closer to extinguishing it.
Having just returned from the region, it is clear to me that the public health emergency is far worse than we could have imagined – despite the availability of nearly 100 per cent effective Ebola vaccine that could help us halt the crisis quickly. The vaccine may have so far prevented it from becoming a fully-fledged forest fire, burning completely out of control. But instead what we have is a smouldering epidemic, with worrying embers already having spread to Uganda and the city of Goma. These were quickly prevented from spreading further, but now a further three cases in Goma in the last week only reemphasises the risk. The vaccine is in danger of causing complacency. And, as difficult as it is for me to say this as the head of an international vaccine organisation, the solution is not the vaccine on its own.
We always knew this epidemic was going to be difficult, given the security issues in the affected parts of DRC, and given its geography and proximity to international borders. But even so we were hopeful that, given the speed of the response and the availability of vaccine doses, we could snuff this out as effectively as we did the last outbreak, which immediately preceded it.
Yet, despite the best efforts of the brave frontline local and international health care workers, the virus is still spreading almost as fast as it did a year ago. We are seeing well over 30 per cent of cases still dying in their communities, instead of being identified and treated in the Ebola Treatment Centres. I am awed by the unprecedented number of people that have been vaccinated in the DRC, more than 181,000, but ring vaccination – where contacts of infected people, and contacts of contacts, are traced and vaccinated – is still proving too slow and often incomplete. In fact, whole chains of transmission are still being missed. And all the while, fear and suspicion are still leading to rumours as well as attacks on health care workers and clinics. Despite this, the only thing keeping this outbreak at bay and preventing it from becoming the worst epidemic in history, is the vaccine.
But in all 27 previous outbreaks including the largest – the 2014 West African epidemic which infected more than 28,000 people and killed more than 11,000– it was not a vaccine that eventually brought them under control, it was standard public health practices: case identification, isolation, contact tracing, infection control and safer burial. So now, while the vaccine has an extremely valuable role to play in helping to contain and end this crisis, it cannot do so unless we also double-down on the traditional public health measures.
Furthermore, we really need to ensure that the vaccination effort doesn’t cause complacency, detracting from and undermining other public health efforts. The emergency response is bringing in much needed resources and funding to the areas, particularly after the World Health Organisation recently declared a public health emergency of international concern (PHEIC). But on the ground, this is now in danger of translating into a gold rush with everyone wanting a piece of the action. During my visit I heard of community health workers striking for higher wages and a pastor offering to include Ebola-related public health messages in his sermons for a proposed US$ 1,000 a shot. And given the relative poverty in these areas, the significantly higher wages offered to health care workers and vaccinators is drawing people from far and wide, who are willing to risk their lives for the rewards it offers.
This not only potentially poses a potential conflict of interest and creates a perverse incentive to not rapidly end the epidemic, it also risks drawing precious human resources away from already weak primary health care in the region. In fact, childhood immunisation in the affected areas has been suspended. This is likely to exacerbate a broader public health emergency that has seen a measles epidemic sweep across the country, with over 120,000 cases and more than 2,000 deaths. These services need to be resumed immediately.
Given the mistrust in the population, a much more effective strategy is needed to increase community engagement and to use local residents who speak the local language and who are more trusted. Recent work has led to hiring 1,600 local community health workers, to provide house–to–house visits to identify cases, and training more health care workers from the local areas as vaccinators are steps in the right direction.
Of course, I am a great supporter of vaccine research. Given the sensitivity of the community, and risk of misinformation fuelled by wide use of social media in the region, if one or more new vaccines are to be researched as some are proposing, it will be especially important to provide excellent communications given how different these vaccines are, so as to not create confusion or further distrust. It will also be important to not distract any of those working on the current response.
From a public health perspective, it is not more vaccines that are needed right now, but rather better implementation of the public health response and the one we have. We know it works, we just need to identify those people potentially exposed to the virus more quickly and more thoroughly. Otherwise we could end up vaccinating another 181,000 people while this epidemic continues to smoulder and spread undetected, until eventually it reaches a heavily populated area or another country with weak public health systems, flaring up into a truly global emergency.
Dr Seth Berkley is CEO of Gavi, the Vaccine Alliance