The Democratic Republic of Congo (DRC)’s eleventh Ebola outbreak was declared over today. Teams with the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) have responded to this outbreak in Équateur province, located in the country’s northwest, since it was declared in June.
DRC is no stranger to Ebola. In fact, the current outbreak in the west that resulted in 130 confirmed cases and 55 deaths was declared while a separate outbreak in the eastern part of the country was still ongoing. That outbreak in the east—which was the tenth in DRC’s history and infected thousands of people—was the country’s largest on record, lasting from August 2018 to June of this year.
The country’s 11th outbreak, this one centered in the western province of Équateur, was less intense and looked quite different from its predecessor. For one, it spread at a slower rate and mainly affected less populated, difficult-to-access areas. This helped to contain the virus and prevent it from reaching more populated urban areas where it could have caused a major spike in the number of cases.
Lessons learned from previous outbreaks also contributed to fewer people getting infected and a lower mortality rate. From implementing a decentralized, community-focused approach that better addresses the needs of people who are affected to having new tools like a licensed Ebola vaccine and new treatment options, health care workers are better prepared to fight Ebola than ever before.
In this interview, Guyguy Manangama, who has led MSF’s Ebola activities, describes the situation following a recent visit to Équateur province, as well as how the medical response has evolved based on lessons learned from previous outbreaks:
Describe the pattern of the Ebola epidemic in Équateur province, and why was it less severe?
The eleventh Ebola outbreak in DRC was declared on June 1. Since then, 130 people have fallen ill, and 55 people have died from the disease. The first cases were reported in the town of Mbandaka, the capital of Équateur province, before small clusters began to appear in the more peripheral districts. Since then, the outbreak advanced at a slow pace.
We have observed significantly lower levels of viral loads and mortality compared to the tenth Ebola outbreak, which struck the east of the country between 2018 and 2020. Mortality is still high at 43 percent today, but it’s down from the 67 percent we saw during the outbreak in the eastern part of the country, in North Kivu and Ituri provinces.
A possible explanation is that some sort of natural immunity exists among people in Équateur province, as this region has experienced Ebola outbreaks before—most recently in 2018. Reservoirs of the virus are traditionally present there. It is possible then that some people may have experienced low-level exposure to the virus before and may be immune in some way.
This is just a hypothesis based on observations. Further analysis is needed to understand. Also, today we are benefitting from the scientific progress made in recent years, including our ability to use a vaccine, as well as curative treatments that have proven to be effective in clinical trials conducted during the previous outbreak in North Kivu.
What are the main differences between the tenth and eleventh outbreaks and how did they affect MSF’s activities?
The previous epidemic [centered in North Kivu] was exceptional in many ways, including that it took place in an area which had never seen the disease before and was a conflict area.
The outbreak [in Équateur] was quite different. We didn’t see large urban clusters, but, rather, sporadic cases that didn’t appear to spread in a linear way. Lacking major long-distance roads, for example, communities move along the meandering waterways of the area as they go from one small village to another. As a result, patients were scattered over a vast area that included 12 of the 17 health districts in the province.
What about the new tools developed during the last outbreak in the eastern part of the country, namely the first and newly-licensed Ebola vaccine as well as the new treatment options that were provided under a compassionate care protocol or as part of clinical trials? What role did they play in the response to the outbreak?
The vaccine was deployed early in the current outbreak and may have played an important role in reducing the spread of the virus. The strategy was based on vaccinating people who had direct or indirect contact with the sick, but in rural and sparsely populated areas it is often more expedient and effective to vaccinate the entire community. This results in a de facto higher level of protection. After some delays, the new treatments were also rolled out in treatment centers.
Today, these tools allow for a radical change in approach. While limiting the circulation of the Ebola virus remained a very important objective for the response, efforts increasingly focused on patient care and recovery.
During previous outbreaks, we could do little more than isolate the sick and provide them with basic treatments for symptoms like fever or dehydration. Having curative treatments at our disposal meant that the patient and the quality of care could take center stage.
Additionally, more progress came in the way of post-exposure prophylaxis. This included administering monoclonal antibodies to people with a high probability of developing the disease, following high-risk exposure to the virus—like through contact with a patient's blood—as long as it is done within 72 hours of exposure. This was especially important in order to protect health care workers on the frontlines [fighting] Ebola.
One of the main challenges in North Kivu and Ituri, in the east of the country, was people’s reaction to the arrival of the response teams. What is the relationship like with the community in Équateur province?
In northeastern DRC, we worked in an unstable context, marred by a very violent conflict that led to political tensions over long periods of time. In Équateur, the environment is much calmer.
The good relationship between health care personnel and local people can also be attributed to the new approach adopted by the response, which was based on empowering decentralized structures for Ebola care in local health care facilities, ensuring that detection and care options are close to patients and communities, relying on local health workers, and limiting the use of large, centralized facilities and imported personnel that may be far from the actual patients in need. In short, we supported the local health care network to identify, isolate, and treat patients with Ebola disease, minimizing the need for a parallel system.
We promoted this approach as early as in 2019, as we tackled the previous outbreak in the east. It has now been adopted by all those involved in the medical response, including DRC’s Ministry of Health, and has many advantages. Large treatment centers are neither appreciated by communities nor easily accepted by patients and their families; they are hermetically sealed, impenetrable... they spark fear. The incomprehension and hostility the centers generated in 2018 and 2019 produced harsh reactions, sometimes very violent.
By having the option of being treated closer to home, in facilities that are known and accessible to their families, patients are much more willing to come forward in case of symptoms. If they are indeed infected with Ebola, early admission to care also increases their chances of recovery. When sending our mobile teams, we also took into account the broader health needs of people aside from Ebola. This also greatly contributed to the good acceptance of our teams by communities.
This deadly virus is at last beginning to look like a very serious but treatable disease—and even a preventable one to some extent through vaccination—rather than a biological threat.