It is now over a year since the Ebola outbreak was formally declared in the Democratic Republic of Congo’s north-eastern provinces of Ituri and North Kivu. The current outbreak is the country’s tenth since Ebola virus first came to public attention in 1976 and is now the second largest in recorded history.
The outbreak shows no signs of slowing down, in large part due to the fact that it is taking place within an active conflict zone. The eastern DRC has been caught in a series of successive conflicts since 1994 that have killed more than five million people, driven more than four million people from their homes, and left 13 million people poverty stricken, struggling to feed themselves.
So, what is needed to get the Ebola outbreak in the DRC under control?
1. Strong leadership from Kinshasa and the WHO
In July Dr Jean-Jacques Muyembe-Tamfum, a distinguished virologist from the DRC was appointed to head the National Institute for Biomedical Research in Kinshasa. In 1974 he was the first virologist ever to see an Ebola patient and he has helped fight all nine of the outbreaks to strike DRC since. He has voiced ambitious plans to bring the outbreak under control in three to four months. His principal aim is to focus on building trust in the communities and entrust as much of the task of reaching out to local health workers, assistants and even medical students – people who speak the local language.
The WHO continues to coordinate the international response and has just released the fourth strategic response plan for the Ebola outbreak.
2. Emergency funding to be made available
The WHO declaration of a PHEIC is designed to open the floodgates to international funding contributions, while being careful not to disrupt trade and international travel that is essential to the economy of the DRC. It is estimated that the EVD emergency will require three times more money than currently provided. Already the World Bank has pledged a further US$300 million to the struggle to control and overcome this outbreak. The biggest individual donors to the previous three plans were the U.K.’s Department for International Development, the World Bank, vaccine alliance Gavi, and the World Bank’s Pandemic Emergency Financing Facility.
3. Increased security for health workers and Ebola Treatment Centres (ETCs)
There have been over 170 attacks on Ebola workers this year, seven of whom have been killed and 58 injured. Around 200 health facilities have been attacked, and in some cases burned to the ground, by members of more than 50 armed groups operating in the area. There are ongoing delicate negotiations between those armed groups and local politicians and community leaders to try to ensure the safety of workers and foster greater trust within the communities affected. The use of armed police and military escorts raises understandable suspicion and fuels attacks by armed groups. The United Nations peace-keeping mission holds a key role in the response to the conflict. They also have a role in providing advisers and trainers for the armed forces of the DRC so that they can better protect and support the health workers in halting the outbreak.
4. Secure border health check-points both within DRC and between bordering countries
There are permeable international borders with Uganda and Rwanda to the east of the DRC and these need to remain manned vigilantly in order to try to contain the virus from international spread. EVD has already spread to Uganda with two cases crossing the border but the victims were quickly identified and taken to ETCs. Sadly they died but there was no local spread, thanks to the urgent response and pre-vaccinated health workers. When the deaths of two Ebola victims in Goma were announced, Rwanda temporarily closed its borders with the DRC, which were re-opened soon after but with an increased presence. There have already been 77 million screenings of national and international travellers, and this has been largely responsible for the very limited spread of the disease beyond the immediate surroundings of North Kivu and Ituri provinces. In a news release, UNICEF said it is training 450 front-line mobilisers who are engaging in education campaigns across South Sudan in the event of spread to the north.
5. Community trust is vital to allow an adequate response
Almost three quarters of deaths from EVD have occurred in the community despite education campaigns and well-appointed ETCs. This is largely due to the mistrust that people have for the medical professionals. Less emphasis needs to be put on the international response and more on local health workers and community leaders. District authorities, traditional leaders, women’s groups and even militia groups must be allowed to take the lead in shaping a culturally acceptable response to reduce hostility and improve access and outcomes. Simple but vital measures such as hand washing sites have been installed in 10,000 key locations in north-eastern DRC. Daily meals have been provided to 25,000 schoolchildren in Ebola-affected areas to help build trust within communities. Over 440,000 patients and contacts have also been provided with food assistance, crucial to limiting movement among people who could spread the disease. Also, late last week the UN’s World Food Program (WFP) announced plans to double food assistance to people affected by the DRC Ebola outbreak.
6. Supply of vaccines needs to be readily available to the health workers
The availability of the V920 vaccine, developed during the 2013-16 West African EVD epidemic, has undoubtedly prevented this outbreak from reaching similar numbers. It has been given to more than 180,000 contacts of Ebola cases, but it has only slowed, not halted, the epidemic. A ‘ring vaccination’ strategy, working outwards from confirmed cases, has been employed to try to contain local outbreaks with some, but limited, success. This strategy is hugely dependent on the availability of the vaccine – at the start of the outbreak the global stockpile numbered 300,000 doses. Merck is confident that they can ramp up vaccine supplies and they have pledged to double the supply by 2020 but it is not clear that even that will be enough. Health workers have experimented with half doses in order to increase the availability. Currently, around 20,000 contacts are visited daily to ensure they do not become sick.
There is also a second vaccine manufactured by Johnson & Johnson that is pending approval, but so far it has not been confirmed for use for the Ebola outbreak in the DRC. It is a new vaccine, and it doesn’t have the same track record as the Merck vaccine, so it is necessary to study the efficacy and potential side effects. J&J claim to have 1.5 million doses ready to go, but though there is hope of providing longer lasting protection (the Merck vaccine has only been shown to be effective for one year), its biggest drawback is that it requires a two-dose schedule. The second shot needs to be given eight weeks after the first and thus it is feared that, in a region where there is a high rate of displacement, many people will be lost to the ‘system’ before they complete the course. However, the J&J vaccine is already being ‘tested’ in health care workers in ETCs in Uganda, where follow-up can be more easily monitored. It has become a highly charged decision whether or not to trial this alternative vaccine in the DRC – Ebola vaccines can only be tested during outbreaks and that explains why they are so difficult to develop. If this opportunity is not grasped then we may have lost a key opportunity for greater protection for the next large scale outbreak.
7. Ready availability of the new monoclonal antibody drugs in all ETCs
Two new drugs are to be made exclusively available to all ETCs with immediate effect. Trials have shown them to be much more effective than previously used drugs and offer up to 90% cure rates according to the current trials, when given early in the course of the disease. The two drugs will now go head-to-head to determine whether one is significantly better than the other.
8. Measles, malaria, cholera and other infectious diseases must not be forgotten
Measles has killed more people, and especially children, in the DRC in 2019 than EVD has in the current outbreak. Immunisation rates in general have fallen significantly and herd immunity is a faroff and currently unattainable target. Mosquito populations have gone unchecked and poverty stricken populations are hugely vulnerable. Once this outbreak is brought under control, the challenge facing the DRC is huge to try to restore a public health programme that, prior to the current crisis, saw the country ranked 176th out of 189 countries and territories on the UN’s human development index.
The recent pharmaceutical advances mean that EVD may soon be re-categorised as a vaccine-preventable and treatable disease. A sense that Ebola is incurable, paired with widespread mistrust of medical workers in the DRC, has hampered efforts to stop the spread of the disease. If education of the affected communities and a cease to the armed conflict that is preventing the response teams from reaching victims and contacts can be achieved, then this outbreak can finally be halted.