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A new outbreak of the Ebola virus that has killed at least two dozen people has sent public health officials scrambling to contain the epidemic as it threatens to spread far beyond the remote jungles of the Congo River Basin — and raises new questions about the World Health Organization’s (WHO) preparations for the next killer virus.
The U.S. government is preparing its most direct response yet to the outbreak that appears to have begun in April, readying staffers from the Centers for Disease Control and Prevention (CDC) to deploy to multiple communities in Congo.
Ministry of Health officials first identified cases of viral hemorrhagic fever when it reached the town of Bikoro earlier this month. On Thursday, officials said a new case had been identified in Mbandaka, a city of 1.2 million.
The new case in Mbandaka has raised the alarm among public health officials because it is the first time the virus has ever landed in a city that sits directly on the Congo River.
In all eight of the previous known Ebola outbreaks in Congo, the virus has been contained within remote jungle villages or relatively small towns, where isolated populations are less likely to spread the disease.
But the Congo River is effectively the region’s highway system. Barges and boats travel from Kisangani in the east through major cities including Bumba, Mbandaka — and eventually Kinshasa, the capital of Congo and home to more than 11 million people, as well as Brazzaville, the capital of the Republic of Congo.
“The Congo River connects three national capitals and multiple other large cities,” said Jeremy Konyndyk, who led the U.S. Agency for International Development’s Office of Foreign Disaster Assistance during the 2014-2015 outbreak. “The fact that there are now several cases in an urban center of more than a million people underscores the potential for this outbreak to get out of control.”
If the Ebola virus traveled upriver from Bikoro to Mbandaka, some officials wonder, has it also traveled downstream toward Kinshasa, which offers direct air traffic to cities including Brussels, Paris, Dubai and Lagos, Nigeria?
“We don't know what's happening along the river, because the river is used by a lot of barges,” said Pierre Rollin, one of the world’s leading experts on the Ebola virus at the CDC. “None of the outbreaks have been by the river or in the big towns. So we have a lot of caution before claiming we know what's going on.”
Previous outbreaks have been snuffed out in the Congo, Rollin said, because the area is so remote that humans did not have a chance to travel far enough to transmit the virus before succumbing.
That was not the case four years ago in West Africa, where the virus spread widely across international boundaries. Commercial and cultural travel throughout Guinea, Liberia and Sierra Leone — across borders drawn a century and a half ago by colonizers with little regard for traditional tribal boundaries — is far more common than it is in Congo.
The present outbreak has raised anew questions about WHO and its capacity to respond to deadly viral threats. Following the West Africa outbreak, when the ill-prepared WHO endured withering criticism for its lackluster response to the initial round of cases, the agency has undergone a remarkable round of self-flagellation, reorganizing to prioritize emergency preparedness and response while cutting bureaucracy.
“We’ve seen WHO activate much more quickly, at much larger scale, and in more effective partnership with players like” Doctors Without Borders, said Konyndyk, who sat on an independent panel that advised WHO on reforming its emergency functions after the West Africa outbreak.
The first WHO investigative team arrived in Bikoro on May 5, about a month after the first suspected cases are likely to have emerged in Ikoko Impenge. A logistics team arrived on May 9, and the United Nations began daily flights carrying supplies and personnel between Kinshasa and Mbandaka on May 13.
Tedros Adhanom Ghebreyesus, the WHO’s director general, visited Bikoro on May 13, in part to show the urgency of the situation.
“A major lesson learnt from the West Africa Ebola outbreak was that WHO needed a flexible fund to rapidly respond to outbreaks and emergencies,” Tarik Jasarevic, a WHO spokesman, said in an email from Geneva. The agency’s new Contingency Fund for Emergencies, already activated in Congo, has made cash available to responders far more quickly than in the West Africa case.
Still, some wonder why it took the Congolese Ministry of Health and the WHO a month to spot the virus in the first place.
“We are doing better at response, but not much better at rapid detection, which is important,” said Tom Frieden, a former CDC director who now runs the public health organization Resolve to Save Lives. “This was spreading for a while before [it was] recognized.”
Aiding the response further is a new vaccine, finalized in the last days of the West Africa outbreak. About 4,000 doses of the vaccine are headed to the epicenter of the new outbreak, where they will be used in two ways: First, health-care workers, those most vulnerable to exposure, will be vaccinated. Then, those who have come into contact with anyone infected, and the contact’s contacts, will be vaccinated, a practice known as ring vaccination.
“That part should really add another arm to the response. It's not the response by itself, because you still have to do all the rest,” Rollin said.
Congo is also far more prepared to respond to an Ebola outbreak because the virus is known to be endemic to the region. The first modern outbreak of the Ebola virus occurred in the village of Yambuku, about 370 miles from the site of the present one, back in 1976.