WHO (World Health Organization)

At any one time, dozens of infectious disease outbreaks are happening around the world.
Those on the frontlines are often more visible, but behind the scenes, many activities are taking place to control the spread of these diseases.
In this special feature, we visit a series of recent health emergencies, telling the stories behind the headlines and exploring the many different dimensions of an outbreak response.
Dr. Khadimul Anam Mazhar thought diphtheria was a disease from the history books. He certainly never expected to see a case, much less to be part of the team trying to control a widespread outbreak. But starting late last year, diphtheria surfaced in the Rohingya refugee camps in Cox’s Bazar, Bangladesh. It became the focus of Dr. Mazhar’s work: he is a WHO surveillance officer assigned to monitor health risks in the camps.
A year on from the start of the crisis, more than a million people have fled violence in Myanmar – one of the largest population displacements in recent history. The area where the tired and hungry families sought refuge lacked even the most basic shelter and infrastructure.
In conditions like these, a disease outbreak was predictable. “Their immunization coverage was really poor. We don’t have any data if they received the vaccines or not,” says Mazhar.
Humanitarian crises, forced migration, environmental degradation, climate change, reduced access to health services and prolonged conflict often provide exactly the right conditions for an outbreak to occur. Diptheria – a bacterial disease that is preventable through a simple inexpensive vaccine – is one such example. Once affecting millions, it had been nearly eliminated over recent decades. It is now making a dramatic comeback – not only amongst Rohingya refugees, but in other vulnerable communities around the world.
While diphtheria was being tackled in Cox’s Bazar, thousands of miles away, WHO teams were responding to another crisis: an outbreak of Ebola in the Democratic Republic of the Congo (DRC), a country with long-running conflict, widespread poverty, and a weakened health system. The threat of further transmission was high because the disease affected four separate locations, including Mbandaka, a major city with connections to the capital, Kinshasa and to neighbouring countries. In addition, health workers had been infected, becoming potential vectors for the spread of the disease.
WHO and its partners sent teams to DRC within two days of the outbreak being declared, and more than 360 responders were deployed to the affected areas. They supported the country in coordinating the response, raising awareness in communities and facilitating access to vital supplies and medical equipment. On 24th July, health authorities in DRC announced the end of this outbreak in Equateur Province, 12 weeks after the intial cases were declared.
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When crises overlap
The outbreaks of Ebola in DRC and diphtheria among the Rohingya refugees have starkly different profiles. One was a naturally occurring zoonosis in a remote area, the other the result of a major migration of a highly stressed population. One was a response to a high-threat pathogen affecting a relatively small number of people, but with the potential for large spread; the other took place in a densely populated refugee camp. One caught the attention of donors and was well-funded, the other occurred in the midst of a long-running and long-running crisis, limiting the response of international agencies.
For all the differences, however, they also share similar traits: prolonged conflict, inadequate water and sanitation systems, and struggling health systems.
The cases highlight two critical and often overlooked issues: 1) multiple countries around the world are facing severe health crises, and 2) many of these countries have several health crises occurring at the same time. In the case of the DRC for example, the country is also struggling with cholera, malaria, circulating vaccine-derived polio, and malnutrition.
Geography and environment add layers of complexity to the health response. The monsoon season is threatening the makeshift housing in Cox’s Bazar and putting refugees at greater risk of outbreaks. In DRC, health workers have had to operate in hundreds of miles of thickly forested areas, which make up some of the remotest places on Earth.
The many faces of the response
While it is critical to treat patients affected by epidemic diseases, the response is much more than purely medical. The range of necessary expertise includes epidemiologists, logisticians, clinicians, data managers, anthropologists and planners.
And even something as seemingly straightforward – and critical – as vaccination requires quick thinking, as officials discovered when many young Rohingya women were reluctant to be treated by male vaccinators. So health officials worked to quickly recruit and train female vaccinators in order to make sure that as many people as possible were covered by the life-saving immunization.
“The cultural acceptance of health interventions is always a challenge,” said Dr. Sylvie Briand, the Director of the Infectious Hazards Management Department at WHO. Evidence from previous outbreaks has emphasized the clear need for including social science experts such as anthropologists to work with communities in outbreak response.
Social anthropologist Julienne Anoko visits communities to help prevent the spread of Ebola
A vaccination day in Cox’s Bazar
Under the radar: protecting health security
While disease outbreaks are often unpredictable and require a range of responses, the International Health Regulations (IHR) provide an overarching legal framework that defines countries’ obligations in handling acute public health risks that have the potential to cross borders. Now a legal agreement between 194 nations around the globe, they grew out of the response to the cholera epidemics that once overran Europe, when countries used quarantine and other measures to respond to the spread of the disease.
Today, the IHR (2005) define when a country is required to report a disease outbreak to WHO and outlines the criteria for when a disease outbreak should be considered a “public health emergency of international concern”, which triggers a specific response.
At the same time, they contain provisions designed to limit the economic impact for governments that sound the alarm when they are facing a public health threat, so that other nations may not arbitrarily impose trade or travel embargoes without providing a clear public health justification.
Behind the scenes of the Ebola response in DRC
The village of Bosolo, where an Ebola vaccination team conducted ring vaccination for people at high risk of contracting the virus.