The World Health Organization took the rare step of classifying an ongoing Ebola outbreak in eastern Congo a "public health emergency of international concern" just days after the first case of the virus was confirmed in the major city of Goma on the border with Rwanda.
The last time the global health body declared an international emergency for Ebola was during the 2014-2016 outbreak in West Africa that killed more than 11,000 people. The designation means this outbreak qualifies for a higher level of global vigilance and mobilization to stem its spread.
Ebola began spreading in Congo's conflict-ridden North Kivu province last summer and has infected more than 2,500 and killed nearly 1,700, according to official Health Ministry figures.
The WHO declaration represents its highest level of alert. It is invoked in response to only the most dire threats and has been issued just four times before.
The first time was in 2009 during the H1N1 influenza epidemic that is believed to have infected up to 200 million people worldwide; the second in May 2014 when a paralyzing form of polio re-emerged in Pakistan and Syria; the third in August 2014 with the Ebola epidemic that devastated West Africa; and the fourth in February 2016, with the Zika epidemic in Brazil.
The decision was made by a committee of 10 scientists who had three times earlier declined to issue the declaration for the current outbreak.
The committee said delays in funding had constrained the response and hoped the declaration would add to the international community's sense of urgency. But members also cautioned against using the declaration to impose punitive travel restrictions on countries in the affected area.
The declaration should not be used "as an excuse to impose trade or travel restrictions, which would have a negative impact on the response and on the lives and livelihoods of people in the region," said Robert Steffen, chairman of the Emergency Committee.
That a case of Ebola would be confirmed in Goma was a major concern since the beginning of the outbreak, given its size and that tens of thousands cross the nearby border with Rwanda on foot every day.
The patient ended up being a Goma-based pastor who had gone to Butembo, another city of more than a million, near the outbreak's epicenter. He died Tuesday, and WHO officials are tracing dozens of contacts he made.
A new vaccine had some success in slowing Ebola. But the rate of infections has increased recently, and health workers worry some cases are going unreported, making the virus's spread harder to contain.
Attacks by armed groups and violent pushback from locals frustrated by the ubiquitous presence of health workers have forced the international response to pause from time to time, allowing the outbreak to grow.
There have been about 200 attacks on health workers since January alone, and seven have been killed.
"This is the most complex environment there is for an Ebola response," David Gressly, the United Nations' emergency response coordinator, said in an interview last month in Goma, North Kivu's capital.
"We are still at least months away" from a conclusion, he said.
North Kivu has an international airport and two international borders and is close to two others. The province is closely linked by business, family ties and language to communities across the borders in Uganda and Rwanda.
Besides the province including Congo's sprawling capital, Kinshasa, North Kivu is the vast country's most populous.
On Wednesday, a fisherwoman died of Ebola in Congo after having spent time last week in Uganda, where she reportedly vomited repeatedly in a market. WHO said nearly 600 fishmongers in Uganda might be targeted for vaccination but that no confirmed case had yet been found to have stemmed from the incident.
In June, three people belonging to the same family who were sick with Ebola traveled to Uganda seeking medical treatment. A 5-year-old boy and his 50-year-old grandmother ultimately died in Uganda, and another family member was repatriated to Congo.
About two dozen "active cases" have been caught at border points since the outbreak began, according to the WHO. Uganda has experienced multiple outbreaks of Ebola and similar viruses since 2000.
"Uganda is well prepared, because of their experience with Ebola, and Rwanda is because of a strong health system, but in Burundi and South Sudan there is a huge gap in readiness," said Jean Felix Kinani, the WHO's head of preparedness and readiness operations in Goma.
The WHO and other public health organizations have been tracing giant webs of people who have come into contact with suspected or confirmed cases. Most contacts remain in Congo, but a significant number have been tracked down in neighboring countries, and two others made it as far as Dubai and China before being tested for the virus.
US officials maintain that the risk of the virus spreading beyond the region is low, and that Uganda, Rwanda, Burundi and South Sudan are at greatest risk because of the number of people from North Kivu who move across portions of those borders where there are also no health checks.
They have also expressed concern that many cases may be going unreported as conflict and lack of infrastructure limit accessibility to many areas.
US officials have described as "arbitrary" the WHO guidelines on declaring a public health emergency.
Appearing before a House panel June 4, Centers for Disease Control and Prevention Director Robert Redfield was asked about earlier decisions by WHO to refrain from declaring the Congo outbreak an international health emergency.
"I will say that nothing about their decision to declare it or not declare it is impacting the United States' ability to respond," Redfield said. "It really basically is a consequence of their arbitrary guidelines that the committee has about calling it."
The fact that the CDC has already activated its own emergency operations center "speaks on its own," said J. Stephen Morrison, a senior vice president at the Center for Strategic and International Studies in Washington who has tracked the outbreak. "They see it as an emergency."
But the United States' presence on the ground is extremely limited, as CDC workers are barred from entering the zone of active infections, partly over security concerns stemming from clashes there.
Congo has had nine previous Ebola outbreaks, and the current one is the longest and deadliest. More than 115 health workers have been infected.
"All we can do is try to smother it," said Kinani, the WHO head for preparedness.
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