12. DISCUSSION

      As of June 2019, the northeastern DRC Ebola virus epidemic remains uncontrolled after 12 months. As people across the world realize the dangers of this outbreak, a handful of leaders within the G20 are only now waking up to the global biosecurity threat of this outbreak. With little international government support or resources, the coalition effort is much farther behind in controlling this outbreak than at a comparable time in the 2014 Ebola virus epidemic.

      The WHO coalition’s poor access to resources has a direct impact or their activities. Among the items they urgently need are an expansion of triage and isolation capacities, waste management resources, more resources required to decontaminate medical equipment and a need for more personal protective equipment (75). The DRC healthcare workers and their extended staff which includes contact tracers, translators, social scientists and others are the backbone of efforts to end EID outbreaks. The most important elements which complicate the containment efforts are militia and civilian oppositional forces fighting against civilians and coalition health care teams fighting the outbreak. Fragmented efforts to control the outbreak lead to a rapid upsurge in the rate of new Ebola virus infections from mid-April 2019 to present (76).

      Recent information from the WHO Situation Report shows that within the 21 days from May 13 to June 2, 2019, 297 new cases were detected (77-78). At an average of 16 new cases per day, this April to June 2019 infection rate is 4 times the rate of new cases per day since the beginning of April. Could any developed country’s specialized hospital to treat EIDs manage a case load of 100 new Ebola virus disease patients every week for months while avoiding Ebola virus spillover into nearby communities? If not, even with the gallant efforts of the WHO regional and international partnership, why should we expect a developing country without resources to carry such a great burden while the developed world sits on the sidelines ignoring their own impending fate? What will happen to the region and the world under such a large and growing EID/ Ebola virus case load? With or without a WHO PHEIC declaration, governments must act for their own self-preservation to bring peace to the region and end this outbreak (79-80).

1. The Ebola virus will not restrict itself to the DRC’s northeast provinces, as there are no geographical or biological boundaries to contain the outbreak. Modern EIDs using 21st-century transportation can cross regions and the globe within a matter of days, infecting and perhaps killing tens to hundreds of millions of humans and animals across continents.

2. EIDs will enter distant countries because disease-carrying hosts do not initially show overt symptoms of EID infection. Expert analysis and tabletop simulations have exposed the many infrastructural, communications and resource vulnerabilities that enable pandemics to sweep across ‘low-risk zones.’ Regardless of the depth of their technology or the strength of their health care systems, EIDs, pathogens of pandemic potential, can relatively easily penetrate any nation. Once in a new urban environment, EIDs like the Ebola virus can hide and multiply exponentially in underserved populations where weak health care systems exist. Initially misdiagnosed, these local EID outbreaks will expand as new regional epidemics.

3. Detecting afebrile (feverless) Ebola virus disease patients is challenging and represents an important reason that Ebola virus outbreaks are difficult to stop. At a minimum of 10% to 13% of total active cases, the acutely afebrile population, with their surge dependent preclinical cohort, can make up a significant percentage of the actively infected population (31-32, 81). Because the afebrile population is large, can fluctuate significantly during surge periods within outbreaks and poses special surveillance issues, this population is important to follow. It may be statistically, if not strategically, useful to post a ‘calculated guess’ of the total percentage and numerical value of the afebrile population along with the total number of active infections in the weekly WHO DON report.

Detecting the afebrile patient in an outbreak environment is difficult. If the DRC suspected Ebola patient gets to a clinic, it may take up to 3 days from initial symptoms for a person to test positive for Ebola virus (31). Incorrectly placing patients in the wrong category can endanger the patient on one hand or the public on the other. During an Ebola virus outbreak, the pressures of screening over a thousand suspected patients a day, many of whom have fever unrelated to Ebola virus infection, in a wide geographical region, makes searching for and identifying afebrile Ebola virus patients all the more difficult (32, 81-82).

4. Vaccines have proven to be a useful tool in controlling this Ebola virus outbreak. Yet, with an expanding Ebola virus epidemic, the decreasing stockpile of the Ebola virus vaccine and its implications have not been conveyed to governments across the world. Using the new vaccine administration directives, the Ebola virus vaccine stockpile even if tripled, could only reach 10% to 15% of the DRC northeast province populations.

While experts have been careful to state that vaccines against EIDs are an important weapon for preventing pandemics, some politicians have overstated the usefulness of EID vaccines, suggesting that vaccines are a potential cure for EID outbreaks (39, 81, 83). Confusion over the messaging that ‘vaccines are a potential cure for most EID outbreaks’ may be another reason that there is a poor international response to this Ebola outbreak. EID vaccination programs, no matter how successful, do not replace the work of identifying EID cases and isolating them to break the infection chain. Vaccine programs aid this effort by slowing the numbers of newly infected people, making control of the outbreak more manageable.

5. The Maginot Line, a massive post–World War I structure, was built by the French in the 1930s to stop any future German offensive, should a second world war between these nations occur. The 450-kilometer (280-mile) ‘line of death’ was a long series of interconnected concrete fortifications with artillery that faced Germany and enough room to house hundreds of troops, connected by an underground railway. By the fall of 1939, World War II began and the German offensive would circle around the Maginot Line, devastating the Allied Forces.

Some developed nation’s strategies to avert pandemic spillover are misplaced as they repeat the tactical errors made by the creators of the Maginot Line, spending billions in funds and resources on their national biodefense budgets. Nations must have defenses for detecting and isolating EID cases that cross into their territories. And just as important as defensive measures is jointly building forward offensive measures like surveillance, strong health care systems, healthcare training and education in nations prone to outbreaks. This dual offense defense strategy minimizes the risk of EID global spread and gives early detection warnings to aid nations which require assistance. Since the violent incidents of April through July 2019 against healthcare workers and civilians, this outbreak’s active Ebola virus caseload is surging. Without swiftly reinforcing external support systems and resupply lines, the healthcare workers and their critical support staff who are the experienced front-line troops of this outbreak will suffer setbacks. Many of these DRC and international healthcare workers have been involved for half a year or more and are experiencing burnout and exhaustion. These front line heroes are the backbone of global biodefense against EID pandemics. They should be respected and recognized across the entire world and deserve our total commitment to help solve this problem.

6. A separate long-term approach to control EIDs that shows promise is building world-class health care infrastructures in regions where EID outbreaks are common. Ongoing projects are strengthening public health while training regional populations to run world-class medical institutions and conduct research. Regional benefits include making the population self-sufficient for health care needs while improving local economies. Data from these projects show an improvement in the general health of these communities and their pandemic preparedness (84-86). 

Copyright © 2019 Na’eem A. Abdullah All Rights Reserved