1000 Deaths and Rising: The Complexity of DR Congo’s Ebola Outbreak

The Ebola epidemic in the Democratic Republic of Congo (DRC) has officially taken the lives of over 1000 individuals, according to the country’s Ministry of Health. These statistics, which were released at the end of last week, have been accumulating since the outbreak’s onslaught in August 2018. This occurrence is considered the second deadliest in the history of this Filoviridae Virus in the world and the deadliest in the DRC. This specific incidence afflicting humanity is often referred to as the Kivu outbreak due to the initial emergence in this northeastern DRC province; however, the identified virulent strain is the Zaire Ebola Virus which happens to carry the highest rate of mortality of all strains.

The following is an up-to-date timeline of the current Ebola outbreak’s transition to an epidemic:

  • August 1st, 2018: The DRC’s Ministry of Health declares an Ebola outbreak in Mangina, North Kivu
  • August 7th, 2018: Laboratory findings confirm this outbreak is caused by Zaire Ebola
  • October 17th, 2018: World Health Organization (WHO) convenes a meeting about the Kivu outbreak. WHO declares this situation does not constitute the classification of a “Public Health Emergency of International Concern”
  • October 20th, 2018: An armed attack occurs in Beni, Kivu at a health care facility leaving 12 people dead
  • November 9th, 2018: The number of cases in DRC reaches 319 which marks the largest outbreak in the country’s history
  • November 29th, 2018: The Kivu epidemic becomes the second largest recorded outbreak of the Ebola virus in the history of the disease on this planet.
  • December 27th, 2018: There is an announcement of postponement of elections in Benin & Butembo which are two largest cities in Kivu.
  • February 24th, 2019: An MSF health care facility is partially burned down and MSF suspends activities in North Kivu by unknown militants
  • February 27th, 2019: A second MSF health care facility is attacked also by unknown militants and the NGO is forced to evacuate staff and suspend all operations in the province of Kivu
  • March 20th, 2019: The outbreak reaches the 1,000 confirmed cases mark of the Ebola Virus
  • April 12th, 2019: WHO holds an additional meeting but finds the Kivu outbreak still doesn’t qualify as a “Public Health Emergency of International Concern”
  • May 3rd, 2019: The number of deaths secondary to the Ebola virus reaches 1000

Although each explicit manifestation of this deadly communicable disease carries with it seemingly insurmountable barriers in the form of human resources, supply logistics, social tendencies, and global support, the Kivu is particularly devastating due to political uncertainty, lack of trust in the health care system, and civil unrest.

Despite the increase in novel innovations for treating Ebola and even a promising vaccine that can prevent the virus virology, the Kivu outbreak continues to surge ahead and torture the human species in large part to a break down of trust in the medical system. The surge has lead to identifying 126 confirmed cases over a seven day stretch at the end of April 2019 in addition to the aforementioned data confirming this outbreak to be the second largest in the history of Ebola. Despite this, the mistrust has amassed in a disbelief that the outbreak even exists. A study conducted by the Lancet in March 2019 revealed that 32% of the respondents believed that the outbreak did not exist in the DRC, it only served as a way serve the elite’s financial interests. Another 36% stated that the Ebola outbreak was fabricated to further destabilize the surrounding areas. With these sentiments, the responders marked that fewer than two-thirds would actually want to receive the vaccine for Ebola. These perceptions of fellow humans provides an additional barrier to overcome for health care professionals in addition to treating a high mortality rate disease in resource limited settings.

While the mistrust in the healthcare system provides a tremendous intrinsic challenge for the DRC, the civil conflict that has targeted Ebola treatment centers delivers a physical and emotional component of the devastatingly uniqueness of this outbreak. With over 100 armed groups thought to be estimated within Kivu province, this has led to widespread violence causing this area to be difficult to maintain access. Due to the high rate of armed groups and the political unrest, there has been 119 incidents of Ebola treatment centers and/or health workers that have been attacked since the start of this outbreak. A few shocking examples include the murder of Dr. Richard Mouzoko who was a Cameroonian WHO physician and the two torched MSF facilities in the northern part of Kivu that were mentioned in the timeline.

The Kivu Ebola outbreak has been unanimously christened one of the most complex humanitarian crises that faces this fragile planet today – the global health community is attempting to treat a disease with a 50% mortality rate, with inadequate but effective evidence-based treatment options in a resource-limited setting, all while in a treacherous war zone. Although these are insurmountable odds, health care professionals across Africa and other parts of the world are addressing the needs of their patients and communities to defeat this ailment. These physicians, nurses, pharmacists, and so many others are generating trust in the health care system at a grass-roots level in the DRC to combat the negative perceptions and the actual outbreak. This example, that the global health community can learn from, highlights the role each person dedicated to global health needs to undertake before an outbreak batters a part of this fragile planet. The vitality of trust can start to be built through having individual/group conversations truly listen to health beliefs, coming in with an open mind to acknowledge local health treatments to complement evidence-based treatment, providing patient centered care that encompasses their culture and values, supporting capacity-building initiatives that allow humanity to act accordingly, investing both time and resources in local public health care infrastructure, and expressing empathy ubiquitously socially and professionally.

Being part of the global health community, it is imperative that this outbreak is adequately supported by humanity. As fellow humans striving towards a healthier society, health care professionals and public health experts must accompany those tormented by the social factors associated with Ebola and the actual virus through global awareness of the situation, an un-stigmatized compassion for those who contract the disease, and a pragmatic solidarity to address this humanitarian crisis.  

Global News Round Up

Politics & Policies

At the urging of the White House, Germany nixed language referring to “sexual and reproductive health” in a signature UN resolution taking aim at rape in conflict situations, Foreign Policy reports.

Programs, Grants & Awards

The DMU Department of Global Health’s Distinguished Global Health Internships are highly selective research opportunities that enable students to explore global health research topics at various organizations. Students have the opportunity to work with researchers on projects such as conducting systematic reviews to create evidence-based educational materials for worldwide distribution.

Research

A swarm of micro-robots, directed by magnets, can break apart and remove dental biofilm, or plaque, from a tooth. The innovation arose from a cross-disciplinary partnership among dentists, biologists, and engineers.

Diseases & Disasters

Imagine your house is gone. And yet the TV set is still standing.  That’s one of the scenes that photojournalist Tommy Trenchard documented as he visited parts of Mozambique hit by Cyclone Kenneth on Thursday.

Measles continues to spread in the United States, federal health officials said on Monday, surpassing 700 cases this year as health officials around the country sought aggressive action to stem the worst outbreak in decades.

Nearly three weeks since fighting began near the Libyan capital Tripoli, the UN health agency warned on Tuesday that “large numbers” of people are sheltering in medical clinics, while civilians continue to be killed or injured, and refugees and migrants remain exposed to clashes.

Students are currently being quarantined in Los Angeles. Mandatory-vaccination policies have been implemented in Brooklyn. Even President Donald Trump, contrary to prior assertions, today urged people to get children vaccinated.

The Democratic Republic of the Congo (DRC) today reported another double-digit rise in Ebola cases, as local leaders such as traditional chiefs and provincial representatives stepped up their efforts to convince community members to support the response efforts to end the outbreak.

In South Sudan mind-bending horrors abound of war, ethnic violence, rape, hunger and displacement.  But for civilians living in the shadow of conflict, the greatest danger is often being cut off from health services, whether due to violence or lack of development in the vast, remote areas that make up much of the country.

Technology

The CDC is issuing new guidance to clinicians for the treatment of severe cases of malaria.  The action follows discontinuation of quinidine, the only FDA-approved intravenous (IV) antimalarial drug in the United States.

Devout parents who are worried about vaccines often object to ingredients from pigs or fetuses. But the leaders of major faiths have examined these fears and still vigorously endorse vaccination.

Ghana’s long unsung health tech sector is getting global validation with two of its most promising startups being named among five winners for one of the most prestigious social enterprise awards in the world.

Environmental Health

Dozens of cities across the world have declared a climate emergency. Now, students behind the school climate strikes are bringing the movement to Switzerland and Germany. But what does that mean exactly?

Equity & Disparities

Sometimes it is important to go back to basics. For human interaction, one of the basics is language, the system of communication that, when applied at its best, allows us to understand each other, share, cooperate, and pull each other towards a better place. When on a collective journey towards a common objective such as the Sustainable Development Goals, with a rallying cry of “leaving no one behind” and a central aim of “reaching the furthest behind first”, this system of communication is fundamental to move beyond just the rhetorical: to be truly reached, the furthest one behind will need to understand what she is being told, and most likely, that exchange will have to be done in her own language. That principle should apply to all aspects of development, including global health.

The Sustainable Development Goals (SDGs) set by the United Nations (UN) would “remain beyond reach” without adequate financing, an International Monetary Fund (IMF) official said.

Women, Maternal, Neonatal & Children’s Health

Anyone following international development is probably familiar with “stunting” — which in nontechnical terms means children being too short for their age. Over the past decade, as the world has focused unprecedented attention on undernutrition, stunting has taken center stage.

Help is needed urgently from the international community to help some 2,500 apparently stateless “foreign children” at a camp for the displaced, in north-east Syria, a top UN official said on Thursday.

Malnutrition is detrimental to the health of children. As a result of malnutrition, a child’s growth can be stunted. Additionally, both brain damage and physical impairments can arise from malnutrition.

Rates of sexual violence in El Salvador rose by a third last year, with the majority of cases involving teenage girls.

Over 19 million children in Bangladesh are vulnerable to the forces of climate change, says a new study released this month (April) by the UNICEF.

Children in some disaster-prone regions are twice as likely to be living in chronic poverty, according to new research.

2019 Membership Engagement Survey Results

Every year, the membership committee conducts a membership engagement survey to help us better understand how we can engage our members and track how we are improving this effort. On February 12th, we sent out a survey to all members over the APHA Connect list-serv. The response rate was 10.44% (n=237) which is a decrease from last year’s 12% response rate.

Of the members who responded, 38% were regular members (full, discounted, or affiliate), 26.6% were students, 22.8% were Early Career Professionals (ECPs), and 12.7% were retired. Almost half of the respondents 46.4%, have been an IH member for less than a year, 29% have been a member for 1 to 3 years, 7.6% of them for over 20 years. The majority (85.2%) indicated that they intend to renew their APHA membership and 89% of them intend to remain with the IH section.

The most common reason listed as the primary reason for joining APHA was: connecting/networking with other professionals (40.5%), followed by professional collaboration with other researchers/professionals (20.7%). About one-third of respondents indicated that they joined to either attend (11.8%) or present (11.4%) or advocate/lobby (11.4%) at the Annual Meeting.

Respondents were asked how easy it is to get involved with Section activities. On a scale of 1 to 5, with 1 being the most difficult and 5 being the easiest, the percentage of respondents were; 1=6.6% (most difficult), 2=19.7%, 3=42.8%, 4=21%, and 5=10% (easiest). Most (79.5%) of the respondents have never been involved with the section committees or working groups.

A clear majority of survey respondents indicated that they were unaware of the Section’s communications platforms: the section website (65.5%), quarterly newsletter (62%), social media (67%) and APHA Connect (59.4%). A quarter of the respondents are aware of the section website, social media and APHA Connect but do not read. And a quarter of the respondents read the quarterly newsletter regularly. Many of the respondents (71.2%) are interested in using communications platforms to network with other section members and discuss global health research and advocacy programs outside of the Annual Meeting. Most of the respondents (81.7%) are also interested in attending regional meet-up event outside of the Annual Meeting.

Members were asked to indicate if they were interested in learning more about the Section’s committees and working groups and to provide their e-mail address so they can be contacted by our committees with information on how to get involved. Committees that generated the most interest among respondents were Policy/Advocacy (71.2%), Program (31.9%), Student (24.5%) and Mentorship (31.3%). Working groups with the largest number of interested respondents included Global Health Connections (70%), Maternal and Child Health (39.5%), Community-Based Primary Health Care (39.5%), and Climate Change and Health (37.9%).

If you have any questions about the survey or have an interest in additional analysis, please feel free to reach out to Jay Nepal or Rose Schenider of the Membership Committee.

APHA’s National Public Health Week: A Review of Events

APHA’s National Public Health Week was chock-full of fun and educational public health events! If you weren’t able to tune in or attend these events in person, don’t fret! Many were recorded for future visits. Check out this outline of some of the week’s big events below:

  • Monday April 1st: Theme – Healthy Communities
    • Keynote address from reproductive justice expert Joia Crear-Perry who spoke of the importance of grassroots organizing to improve the health of communities. Panelists with other areas of expertise aligned with the different daily themes of the week were also included. Check out the recorded forum here.
  • Tuesday April 2nd: Theme – Violence Prevention
    • APHA pushed out a message regarding supporting universal background checks on gun sales. You can sign the action alert for your state here.
    • APHA’s Mighty Fine discussed violence prevention for #NPHW in a new #HealthiestCities podcast: https://bit.ly/2FMSQtW
  • Wednesday April 3rd: Theme – Rural Health
    • Global #NPHW Twitter chat: Look for #NPHWChat on twitter to see what was discussed! Details about the chat here.
    • There was a Q&A with CDC Director Robert Redfield on public health in 2019. Read the full interview here.
    • There was also a blog from  All of Us Research that discusses how precision medicine can help with health disparities in rural communities: https://bit.ly/2FZKu3l
  • Thursday April 4th: Theme – Technology and Public Health
    • APHA hosted a @GetReady Photo contest for animal lovers. See details here: http://bit.ly/GerReady2019Contest
    • National Public Health Week Student Day: early and mid level career public health professionals talked about how they transitioned from student life to public health workers. See the panelists here (this year’s talk has not been posted yet, but check back soon!)
  • Friday April 5th: Theme – Climate Change
    • APHA pushed out a message about climate change and posted a link where you can #SpeakForHealth and alert members of Congress in your state about your interest and passion to protect the public’s health from climate change. See link here: http://bit.ly/2HwUQty
    • APHA’s Surili Patel discusses the important work of APHA and others to address the health threats of climate change. https://bit.ly/2VqVjkj #NPHW#ClimateChangesHealth
  • Saturday & Sunday April 6th and 7th: Theme – Global Health

These were just a few highlights from the busy week! So much more occurred throughout the seven days. What did you do to celebrate this year’s National Public Health Week? Let us know what you did to celebrate this year’s National Public Health Week for a chance to be featured in our blog or quarterly newsletter. Send us an email at ihsection.communications@gmail.com.

If you didn’t join in on the festivities this year, be sure to tune in next year! If you’re interested in hosting an event for next year, check out this timeline to help with the planning process here.

Repurposing Medications: Reimagining Treatment Options

Last month around the Chinese New Year holiday, a prominent Chinese scientist from Guangzhou Medical University made an announcement that stirred controversy both domestically and internationally while also highlighting a route to combat ailments that global academia and pharmaceutical industries have been attracted to for years. The scientist revealed that his team had been injecting patients with a malaria-causing parasite in order to cure a range of cancers – with two patients seeming to have no cancer cells remaining at the site of tumor and five additional patients having no disease progression out of ten total patients receiving this malarial therapy for at least a year. Although this type of treatment has been attempted in the past in an attempt to combat HIV in the 1990s, the Centers for Disease Control (CDC) and other health governing bodies determined that there was insufficient pre-clinical data to justify human trials during this time period. The controversy revolving around this announcement encompasses the aforementioned determination by CDC, the release of trial results before being published in a peer-reviewed journal, and, most importantly, the possibility of creating a malaria public health emergency for a country due to eradicate the communicable disease by 2020. Although the scientist who underwent this study clearly abdicated internationally conferred health principles, this avenue of repurposing – repositioning, re-profiling, re-tasking, etc – medications and therapy is becoming more appealing to those invested in novel treatment options for both established and emerging diseases.

Throughout the development lifecycle of new chemical entity (NCE), the process for regulatory approval could span over ten to fifteen years with an associated cost of over 2 billion dollars. This has led to an average of only 20 to 30 NCEs being approved by the Food & Drug Administration (FDA) each year. However, through repurposing medications, the development span can be cut to five to eight years at approximately 60% of the total NCE cost – in addition to higher approval rates from regulatory agencies. This repurposing process, as shown by the statistics, is enormously appealing for pharmaceutical companies/investors, but also provides targeted therapy for patient’s disease states at a theoretically lower price than an NCE. Even for rare genetic diseases, repurposing has become common due to only 400 medications being on the market to treat over 7000 genetic conditions. Repurposing is accomplished through the theory of translational research which takes a look at basic scientific discoveries and determining how a medication can be made to match this discovery – for example, examining the molecular pathway of diabetes and then matching it with a chemical entity that has an effect within the pathway like glucagon-like peptide 1 (GLP-1). The known chemical entities are commonly stored in giant databases within academia and the industry. Through big-data analytics, advanced modeling, and high throughput screening techniques, these chemical entities can then be extracted from the databases and determined if it has a possible role in a certain molecular pathway.

This method of establishing novel treatment options ought to be utilized more frequently and effectively, though there are medications over the years that have undergone this type of approval. The following are examples of already approved medications and others undergoing clinical trials:

Approved Repurposed Medications:

  1. Thalidomide, which was originally developed as a racemic mixture of enantiomers for the treatment of morning sickness but found to be teratogenic due to the effect of the (S)-isomer, was later successfully developed by Celgene as a single (R)-isomer product for the treatment of leprosy and multiple myeloma.
  2. Viagra (Pfizer’s sildenafil) was a drug that initially failed as an angina treatment in clinical studies; however, during these trials, its effect on erectile dysfunction was noted and then later approved for this indication.
  3. Celebrex, commonly used in osteoarthritis, works by inhibiting COX-2 receptors. Recently it has been shown that for patients that previously had colon cancer, taking this agent can reduce the risk of additional polyp formation without negative gastrointestinal effects associated with existing treatments.
  4. All-trans retinoic acid (ATRA), which is an acne medication, when combined with traditional chemotherapy, results in complete remission of acute promyelocytic leukemia in 90% of treated patients.
  5. Tamoxifen, a hormone therapy medication, treats metastatic breast cancers, or those that have spread to other parts of the body, in both women and men, and it was originally approved in 1977. Thirty years later, researchers discovered that it also helps people with bipolar disorder by blocking the enzyme PKC, which goes into overdrive during the manic phase of the disorder.
  6. Raloxifene was initially developed to treat osteoporosis, but has since been shown to reduce the risk of invasive breast cancer in postmenopausal women in 2007.
  7. Zidovudine (AZT) was initially developed to treat various types of cancer, but was determined to be ineffective. However, it was repurposed into the first approved HIV/AIDs medications in 1987 and has had a tremendous impact on the progression of the autoimmune disorder.

Repurposed Medications Undergoing Clinical Trials:

  1. The lipid soluble simvastatin is currently undergoing a trial in the UK to assess the efficacy of reducing the progression of Parkinson’s disease. The statin drug class is thought to prevent this ailment through its pleiotropic effects including reducing inflammation, reducing oxidative stress, reducing the formation of sticky bundles of alpha-synuclein, and increasing the production of neurotrophic factors. The results are expected to be released in 2020.
  2. Purdue University received a grant from the National Institutes of Health (NIH) to discover the effectiveness of Ebselen, a chemical entity, against methicillin-resistant Staphylococcus aureus (MRSA), and auranofin, which is FDA-approved for the treatment of unresponsive rheumatoid arthritis, against Clostridium difficile.
  3. Metformin, a first line agent for many diabetics, has been shown to reduce the risk of breast cancer in diabetes patients and is being investigated as a treatment for cancer in many different clinical trials

Although this is certainly not an exhaustible list of the impacts repurposing has had on healthcare, the majority of this repurposing stems from serendipitous observations rather than targeted interventions. Through these unanticipated occurrences, a range of disease states can now be more effectively treated ranging from communicable diseases like HIV/AIDS to mental health ailments including bipolar disorder and Parkinson’s disease to non-communicable diseases. As the rising cost of healthcare continues to devastate humanity and lead to health inequalities, heads of governments, pharmaceutical industries, academia, and nonprofits need to commit themselves into investing their time and resources into this repurposing method. The targeted repurposing interventions are more vital and should be devoted to in order to expand options for health disorders rather than the unexpected observed effects. The financial and health outcomes will lead to novel treatment options accessible to a majority of the world which will allow health care professionals to properly accompany their patients through their disease state.