WHO executive board approves Ebola reform proposals

The World Health Organization's (WHO's) executive board yesterday unanimously approved proposals for improving its ability to handle global health emergencies, such as West Africa's Ebola epidemic, which includes a contingency fund and reforms aimed at improving logistics and staffing.

The vote on the proposals came during a special session on Ebola, held on the eve of the executive board's meeting regularly scheduled for Jan 26 through Feb 3. The executive board sets the agenda for the World Health Assembly, which meets in May.

The outbreak, West Africa's first experience with Ebola, highlighted the WHO's limited capacity to respond to such a large event and a desire from many countries and groups that the organization take on a bigger role as the world's top health emergency responder.

WHO Director-General Margaret Chan, MD, MPH, said in a speech to the board yesterday that the Ebola outbreak delivered some horrific shocks and surprises. "The world, including WHO, was too slow to see what was unfolding before us."

She said an extraordinary outpouring of assistance from many nations, the WHO, and its health partners have bent the epidemiologic curve in Guinea, Liberia, and Sierra Leone, avoiding worst-case scenario predictions. "We must now focus on the proven public health measures needed to get the job done," Chan said.

Getting to zero cases in the three countries is the goal, but will be difficult, she said. "As we have seen time and time again, an upsurge in new cases can follow a single unsafe burial or violence act of community resistance. Both of these high-risk situations are still occurring."

Addressing response gaps

In 2011, a review committee convened to assess how the WHO and the International Health Regulations functioned during the 2009 H1N1 pandemic found that WHO was well-positioned to manage a geographically focused, short-term outbreak but didn't have the systems or capacity to respond to a severe and sustained health emergency, Chan noted.

Against that backdrop, the Ebola outbreak highlighted gaps in the WHO's administrative, managerial, and technical infrastructures, she said, adding that the proposals address the need for a dedicated contingency fund, streamlined responder recruitment procedures, and standard operating procedures for all WHO levels. Chan also said the outbreak points out the need to boost crisis management and field expertise for responding to emergencies at WHO country offices.

At a media briefing last night at the end of the special session, Chan said the executive board expressed strong support for several of the proposals, such as fast tracking the implementation of IHR core capacities, building up a contingency fund within the WHO to boost the capacity for early rapid response, beefing up the global health workforce, and fast-tracking WHO reform measures that dovetail with global health emergency response needs.

A $100 million contingency fund has been discussed as a starting point, she said, adding that the United Kingdom has pledged $10 million toward such a fund, and informal discussions are under way with other countries that are considering following the UK's lead.

More concrete plans take shape

Chan said that when the 2009 H1N1 pandemic review committee revealed shortcomings in global preparedness in 2011, an economic downturn stalled efforts to address the issue. However, the financial outlook has improved, and the Ebola outbreak was a very important wake-up call, she added.

Bruce Aylward, MD, MPH, the WHO's assistant director-general in charge of Ebola outbreak response, told reporters that the proposals are poised to make the most sweeping reforms at the WHO since it was established. He added that representatives from member countries have sent a clear signal that the WHO needs to boost its ability to be an emergency operations organization.

The difference between the pandemic review and the new proposals are that the earlier report spelled out what should be done and the new proposals plot out what members states want the WHO to accomplish in more concrete terms, with a 12-month timeline.

Aylward said the Ebola outbreak is far from over, and much more needs to be done. One telling statistic is the percentage of new cases that are linked to contacts. So far, only 50% of new cases have an identified contact, and though the number is an improvement from a few months ago, it means that responders don't yet "have their hands around the neck of the virus."

Aylward said the outbreak region will enter a rainy season in about 4 months, which will complicate logistics, adding a sense of urgency for health groups to take advantage of a window of opportunity for improving contact tracing and driving down Ebola numbers ever further.

MSF warns of remaining gaps

Doctors without Borders (MSF), which has been at the forefront of the response since March, said today that the downward Ebola case trend in the outbreak region is promising, but it cautioned that a lack of vigilance would pose a threat to progress in the battle against the disease. It said just over 50 patients are currently in its eight Ebola treatment centers.

Brice de la Vigne, MSF's director of operations, said today in a statement that the drop in infections opens opportunities to address big gaps that still remain in the response. "We are on the right track, but reaching zero cases will be difficult unless significant improvements are made in alerting new cases and tracing those who have been in contact with them."

He cited a recent WHO figure that only about half of new Ebola cases in Guinea and Liberia are from known contacts. The data aren't available for Sierra Leone. "A single new case is enough to reignite an outbreak. Until everyone who has come into contact with Ebola has been identified, we cannot rest easy," de la Vigne said.

Information sharing about tracing Ebola contacts among the three outbreak nations is almost nonexistent, he said. In an area where people frequently move across borders, it's important that surveillance teams in each country collaborate immediately to prevent new cases from being imported into areas that are considered free of the disease, de la Vigne added.

In Sierra Leone, Ebola cases are dropping faster in remote rural areas, such as Kailahun district, where a comprehensive response focused early on health promotion, contact tracing and monitoring, and a number of small organizations worked together, MSF said. However, hot spots remain in the capital of Freetown, where contact tracing isn't being done systematically and harsh quarantine measures discourage families from seeking early treatment for the sick members.

MSF said its busiest Ebola treatment center is currently the Prince of Wales facility in Freetown, which has 30 patients as of Jan 24.

Guinea still has 14 of 33 prefectures that are considered active, and new cases are being reported from areas previously reported as calm, such as Boke, Dabola, and Siguiri, MSF said. Response activities are being hamstrung in some areas by stigmatization of health workers and survivors and a reluctance to seek care, it added. MSF has two treatment centers in Guinea, plus a rapid response team to address new disease sparks.

Meanwhile, Liberia's sharp drop-off in cases is evident at the MSF centers, with only two patients today at its ELWA 3 treatment center in Monrovia. The group said safely reopening the country's public health system is an urgent priority, and infection control is a key to tamping down the Ebola risk and restoring people's faith in the health system. MSF is supporting infection prevention and control efforts at 13 health centers and is opening a 100-bed pediatric hospital in Monrovia.

See also:

Jan 25 Margaret Chan speech before the WHO executive board

Jan 25 WHO press briefing audio file

Jan 12 CIDRAP News story "WHO board eyes emergency-response reforms in light of Ebola"

Jan 26 MSF statement

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