The Fight to Get a Vaccine to Center of Ebola Outbreak


Medical investigators will need to overcome the rural region’s extreme logistical hurdles to reconstruct transmission chains, vaccinate contacts and halt the spread.

Image
Health care workers preparing a makeshift center to administer an experimental vaccine in Mbandaka, Democratic Republic of Congo, where the outbreak began, in May.CreditKenny Katombe/Reuters

Aiming to squelch an Ebola outbreak that has infected 54 people, killing almost half of them, aid workers in the Democratic Republic of the Congo have begun giving an experimental vaccine to people in the rural region at the epicenter of the outbreak.

Epidemiologists working in the remote forests have not yet identified the first case, nor many of the villagers who may have been exposed. Investigators will need to overcome extreme logistical hurdles to reconstruct how the virus was transmitted, vaccinate contacts and halt the spread.

“For an epidemic to be under control, you need a clear epidemiological picture,” said Dr. Henry Gray, the emergency coordinator for Doctors Without Borders.

“If you don’t know the stories of the people involved — who their families were, what their jobs were, where they went to weddings and funerals — then you don’t know the epidemic.”

Almost 500 people received the experimental vaccine, VSV-EBOV, last week around Mbandaka, a riverfront city of more than 1.5 million people where four Ebola cases have been confirmed.

Mbandaka is a priority because it is a traffic hub. The Republic of the Congo lies just across the Congo River, and Kinshasa, Congo’s capital of 10 million, is less than 500 miles downstream.

Aid workers are using the ring method: The vaccine is given to groups of people in contact with each Ebola case, such as family caregivers, as well as the contacts of those contacts.

About 7,500 doses are available to vaccinate 50 rings of 150 people each, according to Dr. Peter Salama, the deputy director-general for emergency response at the World Health Organization. An additional 8,000 doses will follow.

Administering the VSV-EBOV vaccine in Mbandaka. Epidemiologists have not yet identified the first case, nor do they know how many have been infected.CreditJunior Kannah/Agence France-Presse — Getty Images

The W.H.O. is monitoring more than 900 contacts throughout Équateur province. As the vaccination program expands to the Bikoro and Iboko communities, where most cases have been reported, teams are relying on contact tracing to identify the most urgent recipients.

“This is where everything gets more complicated,” said Chiran Livera, the operation leader in Congo for the International Federation of Red Cross and Red Crescent Societies.

The villages surrounding Bikoro and Iboko are among the most isolated and densely wooded pockets of Congo. Aid workers must use motorbikes to navigate cratered dirt roads that flood during the rainy season. Maps of some regions are incomplete, and vast gaps in cellular service thwart efforts to report data to central operations.

“Following the virus’s narrative may sounds easy to do on a suburban street outside Chicago,” said Dr. Salama. “But when you’re traveling hundreds of kilometers in a forest by motorbike to find each person, that’s very different epidemiological work.”

If the outbreak worsens, a second vaccination may be offered to health workers. That vaccine, developed by Johnson and Johnson, requires two doses and would take longer than VSV-EBOV’s seven to 10 days to become effective — but may protect health workers for several years.

The Congolese Ministry of Health is planning to deploy up to five experimental treatments, though the two most highly recommended by the W.H.O. may prove impractical in a remote setting.

ZMapp, a cocktail of three antibodies used in West Africa, must be given in multiple doses and must be refrigerated. Remdesivir, a drug developed by Gilead Sciences, requires intensive monitoring of liver and kidney function — nearly impossible for treatment centers without electricity, running water or standard equipment.

Another option, called MAb114, began safety trials earlier this month. Made from the antibodies of an Ebola survivor, it can be crystallized and reconstituted with saline-like fluids in the field.

“These are all investigative products,” Dr. Salama said. Vaccine makers have struggled to show efficacy without live Ebola cases in which to test their drugs. “Many consider this outbreak their chance to prove themselves,” he said.

Drug companies are not alone in that mission.

The W.H.O.’s emergency committee gathered 10 days after the Congolese government notified the organization of an Ebola case, a stark contrast to the West African epidemic in 2014, when the group did not convene until almost 1,000 people had died.

Health care workers arriving at Ngobila Beach in Kinshasa to screen others coming into Kinshasa. The capital of 10 million is less than 500 miles downriver from the outbreak.CreditJohn Bompengo/Associated Press

Since May 8, the W.H.O. has sent 156 technical experts to the region. A mobile laboratory has been set up to expedite case confirmations in Bikoro; another is planned for Mbandaka. A cellular tower has been erected in Mbandaka to help workers trace people who may have been infected throughout the region.

The W.H.O. has more than doubled its budget request to $56 million from $26 million to account for the possibility of the virus may reach an urban setting.

“The biggest problem of 2014 was that there had never been an Ebola epidemic before,” said Ron Klain, the White House’s Ebola response coordinator for West Africa. “This time, there is an intensity, a focus, a pace. No one is underestimating the risk, and that alone is a big advantage.”

Another advantage is context: Unlike West Africa, Congo has experienced eight previous Ebola outbreaks since the virus was identified in 1976. Aid workers who arrived in Kinshasa this month found pre-established surveillance protocols, according to Mr. Livera.

The W.H.O.’s strategy assumes the virus will ultimately infect 100 to 300 people. Each rural case may infect 10 contacts, and each urban case may infect 30. Response activities may continue into July, according to a revised plan released May 27.

Until investigators identify the index case, it is impossible to discern whether the first patient detected in April was truly the first human case or the hundredth, according to Dr. Gianfranco Rotigliano, the regional director of Unicef. Until then, it is impossible to quantify the crisis.

“These are the early days of the outbreak,” Dr. Salama said. “There can be lulls. We’ve seen that before. But there only needs to be one event — a super-spreader, like a funeral — to cause an explosion.”

Puerto Rico Nervously Prepares for Hurricane Season: ‘What if Another One Comes?’


“The limitation we had with Maria is we had no cash to burn,” said the governor, Ricardo A. Rosselló.

Emergency managers and business leaders also are concerned about the logistics of getting aid into Puerto Rico. Maria created a bottleneck at the Port of San Juan, which slowed everything from food to electrical poles.

“What am I most worried about?” Mr. Byrne said. “A ship sinks in the channel in San Juan, and we can’t bring anything.”

Manuel Reyes Alfonso, executive vice president of MIDA, the island’s food industry association, said wholesale and retail businesses continued to experience delays in receiving cargo. “We are not where we’d like to be, or where we should be,” he said.

He worries about a trucker shortage and about slow fuel delivery for generators. Puerto Rico had fuel after Maria, but no easy way to get it to people, leading to endless lines at gas stations and a black market for diesel sales. FEMA had to bring in a fuel barge for its operations.

Food could also be scarce again, Mr. Reyes said, because Puerto Rico continues to impose a tax on inventories. Eliminating the tax could increase food stores to an average of 37 days from 26, according to a survey that the food association conducted of its members in February. A legislative effort to do away with the tax has stalled, Mr. Reyes said, in part because lawmakers have yet to figure out how to make up for the lost revenue.

Photo

Puerto Rico officials worry that the island remains vulnerable to another storm because repairs to the power grid have been slow in some areas, including Las Piedras.

Credit
Erika P. Rodriguez for The New York Times

Rodrigo Masses, president of the Puerto Rico Manufacturers Association, said he had advised businesses to double their fuel storage capacity, keep their generators in shape and designate an emergency contact off the island to relay information in the event cellphone service fails again.

“We’re still not out of the crisis. If we’re hit by another hurricane like this one, we’re going to lose power again. We’re going to lose connectivity again,” he warned. “But the private sector is going to be much better prepared.”

Once the Corps of Engineers departs, the Puerto Rico Electric Power Authority, known as Prepa, will be tasked with completing unfinished repairs to the power grid. At a hearing last week of the Senate Committee on Energy and Natural Resources in Washington, lawmakers sounded skeptical that Prepa, which has come under fierce scrutiny over its early response to the storm, is up to the job. Representative González-Colón has asked FEMA to extend the Corps’ stay.

“We sure want to know that you really are ready,” Senator Lisa Murkowski of Alaska told Prepa’s new chief, Walter Higgins, at the hearing.

“We feel that we are ready,” Mr. Higgins said. But, he added, “I don’t doubt that we will have some growing pains.”

In Las Piedras, which sits on the hills south of El Yunque National Forest, people who have electricity say it goes out often. “If a little bit of wind blows through, we will lose power,” said Roberto Rosado, 53, who still has metal shutters on his sliding doors. “We just lost power now. This is an everyday occurrence.”

Mayor Miguel López, who is known as Micky, recently blocked two of the three power crews from leaving his town. “There was no other option,” said Mr. López, whose unorthodox strategy succeeded in keeping the linemen at work.

His director of emergency management, Xavier Muñoz, said the one upside of Maria was that it had scared residents into taking hurricane plans seriously.

“Shelters are going to get full,” he predicted. “I have 220 cots right now, and I think that’s not going to be enough.”

Continue reading the main story

Despite Millions of Displaced People, Congo Rejects U.N. Aid Effort


The United Nations says challenges to Mr. Kabila’s rule have caused a collapse of political authority, leading to fighting that has displaced 4.5 million people and left 2 million children severely malnourished. It has declared Congo one of the world’s worst humanitarian emergencies on par with Syria and Yemen.

Photo

Joseph Kabila has held on to the presidency since the end of his mandate in 2016 in defiance of the Constitution.

Credit
Junior D.Kannah/Agence France-Presse — Getty Images

To respond to the crisis, the United Nations Office for the Coordination of Humanitarian Assistance organized the donor conference in Geneva on April 13 to make its biggest appeal yet for aid to Congo to provide emergency assistance — including food, sanitation, shelter and education — to more than 13 million people affected by the violence.

Mr. Kita said the calls for assistance are “a demonization campaign.” Congolese officials convened a separate meeting in Geneva with other African officials, asking them denounce the aid effort, according to a diplomat with knowledge of the matter. The other nations did not agree to the request.

Still, diplomats and aid workers say they expect the Congolese government’s opposition to have an effect by making it harder for countries at the conference to agree to donate.

The United Arab Emirates, a co-host of the conference, has already said it would suspend participation if the Congolese government did not support the appeal. Congo also threatened Swedish and Dutch diplomats who helped convene the donor conference, saying they did not consult with their Congolese counterparts and warning of unspecified consequences if the European nations continued with the conference.

Christos Stylianides, the European Commission’s top crisis envoy, said during a visit to Kinshasa late last month that foreign assistance would be ineffective without local government cooperation. Donor nations have already pledged $171 million.

An appeal for aid last year fell far short of needs, as donors provided less than 60 percent of what aid agencies requested.

Jose Barahona, Congo country director for Oxfam International, said he has witnessed firsthand what the funding shortfall means for the ordinary Congolese. His organization had to halve its assistance last year, when promised donor funds did not materialize.

The people left out felt hopeless, he said. He recalled one of them pointing to the ground and saying: “I have two of my younger sons buried here. Do you want me to bury more sons?’”

Continue reading the main story