Ebola: Strategies and Challenges for the Current Outbreak in the Democratic Republic of the Congo

By Katherine Lewis

On August 1^st, 2018, the Ministry of Health of the Democratic Republic of the Congo (DRC) announced an outbreak of Ebola Virus Disease (EVD) in the provinces of North Kivu and Ituri. The outbreak is currently classified as a Level 2 Alert, indicating that enhanced precautions should be practiced. According to the World Health Organization (WHO), there have been a total of 1373 cases (1307 confirmed) and 890 deaths (824 confirmed) as of April 24^th, 2019. The most up-to-date death counts can be found on the Ebola situation reports available on the WHO website.

Once an outbreak occurs, it can spread rapidly through communities. It is suspected that humans are initially infected through contact with infected bats or non-human primates. However, the virus spreads quickly from person to person through contact with bodily fluids (such as urine, saliva, sweat, feces, vomit, breast milk, and semen) from a person who is sick with or has died from EVD or through objects (for example, needles) contaminated with such bodily fluids. According to the Centers for Disease Control and Prevention (CDC), the virus may also be transmitted sexually in certain cases because it remains in the semen of male patients, even if the patient has recovered from EVD and is no longer symptomatic. In this case, the virus can be spread through oral, vaginal, or anal sex.

Ebola is caused by a virus and is very rare, but extremely dangerous due to the lack of an effective vaccine or treatment. According to the CDC, current research on Ebola is focused on “finding the virus’ natural host, developing vaccines to protect at-risk populations, and discovering therapies to improve the treatment of the disease.”  There is still no vaccine approved by the Food and Drug Administration (FDA) to prevent Ebola, however, an experimental vaccine called rVSV-ZEBOV was “extensively tested in phase 1-3 clinical trials in North America, Europe, and Africa” following the 2013-2016 Ebola epidemic in West Africa.[1] Additionally, a report published by Ellen Suder et al. concluded that it “is a safe and efficacious vaccine for use in humans.”[1] The West African epidemic inspired the acceleration of Ebola vaccine research, but the rVSV-ZEBOV vaccine has yet to be licensed and clinical trials are ongoing. Side effects of the vaccine including headache, fatigue, muscle pain, and mild-fever have been reported, and more research is needed to understand how long protection lasts. Despite this, the vaccine is currently being used under “expanded access”, also known as “compassionate use”, in the fight against the current DRC Ebola outbreak. This implies that it is being distributed on a limited basis since it may help prevent the spread of the virus, but it is not an officially recognized treatment.

According to the WHO, since it is still not licensed the rVSV-ZEBOV vaccine is currently only being distributed to high-risk individuals following a “ring vaccination” strategy. In this approach, a patient is laboratory confirmed and a ‘ring’ of high-risk individuals are identified based on contact with the infected individual. This group includes ‘contacts’–those who recently lived with the patient, visited the patient, or were in close contact with the individual’s body or bodily fluids–as well as ‘contacts of contacts’–those who live with or have come into contact with those in the previous group. It is also recommended that health care and frontline workers receive the vaccine if they will be interacting with Ebola patients. The ring vaccination program is voluntary and is administered by trained vaccination teams.

Despite the ease with which Ebola spreads through human populations, the virus cannot be transmitted until a person develops signs or symptoms of infection. This emphasizes the importance of identifying symptomatic individuals and isolating them before the virus can spread further. The realization of this approach rests largely on the WHO’s Infection Prevention and Control (IPC) strategy, which is “a scientific approach and practical solution designed to prevent harm caused by infection to patients and workers…grounded in infectious diseases, epidemiology, social science, and health system strengthening.” This strategy encompasses 5 main functions: leadership, connecting, and coordinating; campaigns and advocacy; technical guidance and implementation; capacity-building; and measuring and learning. This approach is actively being implemented in the DRC through the decontamination of healthcare facilities, distribution of supply kits, and training of healthcare workers in new IPC strategies.

Such public health campaigns require careful coordination between international and local health workers in order to develop a relationship of trust between locals and foreign aid workers, such as those from the Red Cross and CDC. In order to ensure that the concerns of the community are expressed, communication between these groups is crucial. According to the WHO, in areas with the highest frequency of incidents, “an anthropologist first meets with the community to ascertain their concerns, then arranges for communal meetings where these concerns can be discussed, including amongst local youth leaders, women’s associations, traditional practitioners, and healthcare providers.” The WHO states that such “community engagement efforts to encourage greater local participation and ownership of the outbreak response [are] ongoing and [have] yielded some success in many areas.” Such efforts include the establishment of community centers to facilitate dialogue between locals and foreigners.

In addition to the difficulties of treating such a vicious disease, medical teams are also challenged by the persistence of violence in the region, which directly impedes their efforts. According to the WHO, the “persistence of pockets of community mistrust, exacerbated by political tensions and insecurity, have resulted in recurrent temporary suspension and delays of case investigations and response activities in affected areas; reducing the overall effectiveness of interventions.” Such violence increases the time it takes medical personnel to identify and treat probable cases and contributes to increased population movement, both of which allow the disease to spread more rapidly. More severe violence against medical teams has also been reported in the regions of Katwa and Butemo and represent “the first large-scale organized attacks targeted directly at the Ebola response.”

In a similar incident in November of 2018, operations were suspended following an attack from an armed group against UN peacekeepers in Beni, a city in the North Kivu province. According to the DRC’s Ministry of Health, “peacekeepers reacted immediately, pushing the rebel group [back] after several hours of fighting a few meters from the Ebola Response Emergency Operations Center and hotels in which several teams from the response were lodged.” Brutal violence against civilians by armed groups such as the Allied Democratic Forces (ADF) have inspired joint offensive operations by the Congolese armed forced (FARDC) and the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO). According to a statement by the United Nations in November of 2018, “FARDC and MONUSCO forces identified, attacked, and managed to retake key ADF positions. A number of ADF elements were also captured.” Such violence contributes to the death toll and challenges the efforts of Ebola response teams not only with civilian and fighter deaths but also by making medical work more dangerous and less effective at preventing the spread of Ebola.

References:

[1] Ellen Suder, Wakako Furuyama, Heinz Feldmann, Andrea Marzi & Emmie de Wit (2018) The vesicular stomatitis virus-based Ebola virus vaccine: From concept to clinical trials, Human Vaccines & Immunotherapeutics, 14:9, 2107-2113, DOI: 10.1080/21645515.2018.1473698