Ebola outbreak in Democratic Republic of Congo: October Crisis Update

At a youth forum in Beni’s city center, MSF project medical referent Jean Pierre Kaposo explains the Ebola vaccination campaign, prevention, and treatments to young community leaders.
Democratic Republic of Congo 2019 © Samuel Sieber/MSF
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The current Ebola outbreak in Democratic Republic of Congo (DRC) is the worst on record in the country and the second-largest epidemic of the disease recorded anywhere. Almost a year after the declaration of the outbreak, more than 2,100 people have died from the virus.

The Ebola crisis in DRC continues to pose a threat to local communities—despite a massive international response, promising new vaccines and treatments, and improvements in the medical management of the disease.

On July 17, 2019, the World Health Organization declared the Ebola outbreak in Democratic Republic of Congo to be a public health emergency of international concern.

Ebola is not the only public health emergency in DRC. The main causes of mortality in the eastern region remain preventable diseases such as malaria and measles. In many health zones, only limited health care is available, as was even before the Ebola epidemic. Many health workers are now missing in hospitals and health centers across the region because they have been recruited by the internationally-funded and well-paying Ebola response elsewhere. The staff shortages and a lack of financial resources and medical supplies for non-Ebola medical needs threatens to further weaken the health system and lower communities’ acceptance of the Ebola response.

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A substantial amount of resources have been invested in the Ebola response since the beginning of the epidemic. MSF strongly encourages actors and donors to consider the wider needs of the population rather than focusing response efforts on Ebola alone.

Ebola situation report as of October 2, 2019:

Total cases: 3,198 
Total deaths: 2,137
Survivors: 995

*Data reported by the DRC Ministry of Health and published by the World Health Organization. "Probable" deaths refer to deaths that were linked to confirmed Ebola cases but not tested before burial.

People have been reported to have Ebola in North Kivu, Ituri, and South Kivu provinces, with the current hotspots located in Ituri province.

While the rate of transmission has appeared to slow down over the past month—averaging 47 new cases per week in September compared to August’s weekly average of 65 news cases—the overall fatality rate remains high. In total, 157 new Ebola cases were identified during the month of September, compared to 306 newly identified cases in August.

The Ministry of Health officially declared the latest outbreak of Ebola virus disease in North Kivu on August 1, 2018, but the outbreak likely began months earlier. This is the tenth outbreak of Ebola in DRC in 40 years and by far the country's largest ever documented. It is also the second largest Ebola epidemic on record, behind the West Africa outbreak of 2014–2016.

Ebola response

Doctors Without Borders/Médecins Sans Frontières (MSF) is an active player in the Ebola response. MSF is caring for patients in four Ebola Treatment Centers (ETC) in Bunia, Beni, Goma, and Mwenga, as well as numerous decentralized isolation and transit facilities, where people with suspected cases of Ebola are tested before going to a treatment center. if needed. MSF is also supporting infection prevention and control (IPC) in local health care facilities and vaccination activities in the region. Our main priorities are to assess community health needs, provide timely health care to Ebola patients, ensure appropriate IPC standards in health care facilities, and improve access and quality to non-Ebola-related health care.

MSF projects follow an integrated approach, aiming to support health centers and hospitals, investing in primary and secondary health care together with Ebola related activities. MSF does not have any projects that focus on Ebola alone.

Since early September, MSF has been supporting Ebola vaccination activities in Beni with three teams. Additionally, in several projects in the area, MSF is supporting routine and mass vaccination campaigns against measles, a primary health concern identified by communities in the region.

In total, 13 health zones in northeastern DRC have reported people who have Ebola in the last three weeks. While the city of Goma—the capital of North Kivu and a city of two million people located on the Rwandan border—hasn’t identified any additional people with Ebola for more than two months, the current hotspots are now shifting from North Kivu to Ituri province with Mambasa, Komanda, and Mandima reporting more than 50-60 percent of all recent cases. Mambasa is currently the primary hotspot, and there are not enough beds at the moment to admit all people who are suspected or confirmed to have Ebola. Another hotspot is Kalunguta in North Kivu.

Key challenges

Ending the Ebola outbreak remains a complex endeavor. While fewer people have been confirmed to have Ebola in recent weeks, the epidemiological data show that further efforts are needed to improve the response. New Ebola patients are confirmed with an average delay of five days from the onset of symptoms to diagnosis—a time in which they are infectious to others and miss out on the benefits of receiving early treatment that would improve their chances of survival.

Only 25 percent of new Ebola cases in the overall outbreak—33 percent in the last two months—are identified and monitored as contacts of people previously confirmed to have Ebola. Two-thirds of direct and indirect contacts are lost or never followed-up with, risking further transmission.

The new treatments for confirmed Ebola patients that are available in ETCs are used under a study protocol framework that does not allow access beyond a particular patient or health worker. Extended use, like for additional protection for high-risk contacts, is not currently supported by the protocol. While confirmed patients and health workers benefit from the medication, their overall use remains restricted.

Persisting fears and misconceptions around Ebola treatment facilities and vaccination activities in local communities pose an additional challenge. A third of all deaths have occurred in people’s homes and communities where treatment was not available, and people weren’t properly isolated to minimize the risk of spreading the disease.

Additionally, fighting between armed groups as well as targeted violence can limit crucial activities like vaccination, surveillance and contact tracing, community health promotion, and safe burials in some areas. While it is paramount that health care providers and their facilities are respected, it is equally as important that health care providers work to truly earn the trust of the communities they seek to serve.

Community engagement

Putting communities and patients first—and treating patients as people, not biological threats—is crucial to ending the epidemic. Community dialogue and engagement must form the cornerstone of the Ebola response.

For many communities across the affected region, the Ebola outbreak is only one of several pressing medical concerns. Of patients admitted to Ebola transit and treatment centers with symptoms like fever, vomiting, or diarrhea, only four percent have tested positive for Ebola while 96 percent have other health needs. For most of the epidemic, the response has too narrowly focused on fighting Ebola while other concerns have gone unheard and neglected. As a consequence, health and humanitarian workers risk losing the trust and acceptance of the very communities they are trying to serve.

Where communities ask for health care services for illnesses other than Ebola, their needs should be taken seriously and an appropriate response implemented alongside, or sometimes before, direct Ebola-response actions. Several MSF projects have adjusted their approach based on lesson learned since the outbreak began.

In all our Ebola emergency and regular projects in the region, MSF is committed to planning, implementing, and evaluating activities with input from the communities we serve. MSF projects start with an open community dialogue exploring needs and assessing what MSF can do to meet those needs. In Biakato, the community asked MSF first to build water points and support primary health care before asking for a transit center for suspect Ebola patients. In Beni, MSF decentralized isolation zones to local health centers bringing them closer to communities. All MSF ETCs and Ebola transit centers are supported by community outreach and health promotion activities, including messaging on the Ebola epidemic as well as other key health and hygiene information.

Vaccination

The main vaccine that has been used throughout the outbreak—one that’s produced by Merck pharmaceutical corporation—is estimated to offer effective protection for 97.5 percent of participants ten days after vaccination and is a promising tool in the fight to contain the outbreak.

However, due to the limited use and investigational status of the vaccine, the vaccination strategy is limited to a “ring approach.” This means only contacts of people who likely or have been confirmed to have Ebola and their contacts—plus frontline workers like doctors and humanitarian staff who are most likely to interact with people who have Ebola—are eligible to be vaccinated.

The “ring vaccination approach” strongly depends on successful contact tracing, which has been notoriously difficult in DRC with an estimated 66 percent of contacts in the last three months not being followed, and 75 percent in the outbreak overall. MSF supports the Strategic Advisory Group of Experts’ (SAGE) recommendations to begin geographic vaccination, use pop-up sites, and expand vaccination activities.