How West Africa’s Ebola outbreak shapes response in DRC

Countries know the risks – and they know they have to act fast.

This is the biggest lesson learned since an outbreak of the deadly Ebola virus struck three countries in West Africa, leaving more than 11,300 people dead in its wake, said Chikwe Ihekweazu.

An infectious disease epidemiologist who worked in 2015 – at the height of the outbreak – in Liberia, Ihekweazu said containment efforts were particularly challenging since it was the first time the disease had hit West Africa.

The health networks in Liberia, Sierra Leone and Guinea – the latter being where the first case of Ebola was discovered in the outbreak in late 2013, in an isolated, rural village – were ill-prepared to deal with the virus, which has no known cure.

“The uncertainty of what to do, the lack of institutional structures in West Africa to deal with a severe infection like Ebola, and the lack of knowledge about the disease” contributed to its spread, said Ihekweazu, now the national coordinator of the Nigeria Centre for Disease Control.

Transmitted through bodily fluids, Ebola spread rapidly across the region. Before the outbreak ended in 2016 there had been more than 28,600 cases.

Now, as the Democratic Republic of Congo (DRC) grapples with its own Ebola outbreak – the ninth since the virus was first discovered there in 1976 – health experts say what happened in West Africa can help shape the response to the disease. 

“The level of engagement of both the country and the international actors has changed completely,” Ihekweazu said.

“People do realise that this is not something that you can say, ‘This is a small corner of the world [so] it’s their problem.’ We can’t abdicate the responsibility because it’s happening somewhere else.”

Controlling the disease

The DRC government officially declared an Ebola outbreak on May 8 after laboratory tests confirmed two cases of the disease in the town of Bikoro, in the country’s western Equateur province near the border with the Republic of Congo.

Confirmed and suspected Ebola cases have been recorded in Bikoro, the villages of Itipo and Iboko, and in Mbandaka, a city of about 1.2 million people on the shore of the Congo River.

By May 30, the World Health Organization (WHO) said 37 confirmed cases and 13 probable cases of Ebola have been found in the DRC since the start of the outbreak.

In total, there have been 50 cases linked to the virus, including 25 deaths, the WHO said.

On June 1, the DRC’s health ministry reported five new suspected cases: three in Bikoro and two in Wangata, an area of Mbandaka in which the outbreak has been centred.

Only three cases have been confirmed by laboratory tests, however.

The most recent outbreak in the country, in May 2017, resulted in four deaths in northern Likati district.

Most of the past outbreaks affected remote parts of the country, said Luis Encinas, the emergency medical coordinator at Doctors Without Borders, known by its French initials – MSF, and an expert on Ebola, who is currently working in the DRC.

“The fact that populations weren’t moving around helped quickly control” the disease, he told Al Jazeera.

That differs from the start of the outbreak in West Africa in 2014, which occurred in a border area. 

The fact that emergency health responders were dealing with “three countries less than 60km from each other, three health systems, [and] two different languages” made that situation much more challenging to contain, Encinas explained.

“It was complicated also because it was the first time that Ebola was declared and identified in that region of Africa. It wasn’t like in DRC” where the disease has been found more frequently, he said.

Different from past cases

Still, the current outbreak in the DRC differs from the country’s previous ones, as confirmed and suspected Ebola cases have been identified in several places at once, said Michelle Gayer, emergency health director for the International Rescue Committee.

Reports of Ebola in Mbandaka have prompted the most concern over the disease potentially spreading even further – and threatening even more people – f it’s not properly contained.

Mbandaka lies on the Congo River, an important transport artery linking the region to Kinshasa, the DRC’s capital, and Brazzaville, the capital and largest city in the Republic of Congo, just across the border. 

“A city is dense. People move around a lot. Rumours can spread quickly. It’s hard sometimes to spread the right messages because there are so many different avenues of communication and people seek care from all sorts of places,” said Gayer, who is currently based in Kinshasa.

“Often in a small village, you’ll just have one traditional healer. In a city like Mbandaka, you’ve got traditional healers, local pharmacies … [and] there are well over 55 health facilities.”

Gayer said experts believe a person with Ebola in a rural area will come into contact with about 15 other people; in a city like Mbandaka, that figure jumps to around 50 contacts.

Ebola’s symptoms – fever, headaches, muscle pain, bleeding -can also show up between two to 21 days after someone comes into contact with someone with the disease, meaning people need to be monitored that entire time.

“It’s just a really tough job, teams wandering around, systematically going through villages, through the bush, trying to find these contacts,” Gayer said.

“And then, when you miraculously find them, you have to monitor them for 21 days, as well, and then make sure that those people, if they do develop symptoms, they come seek care as soon as possible.”

Jessica Ilunga, spokesperson for the DRC’s ministry of health, said the biggest lesson it took from the West African outbreak in 2014 is that the government needs to take a leadership role in the response, as many organisations will want to help.

“The risk with that is ending up with dozens, if not hundreds, of different actors working according to their vision and priorities. That’s one of the elements that slowed down the response in West Africa,” Ilunga told Al Jazeera in an email.

She said the government’s response to an Ebola outbreak remains the same whether the disease has been found in a rural or urban area.

In both cases, it must make sure the population respects hygiene best practices, rapidly take care of and identify cases, and follow up with people who have had contact with someone with Ebola.

“The only difference is that the proximity and density of the population in urban areas makes the work of epidemiologists more difficult and identifying the cases and contacts becomes a genuine race against the clock,” she said.

Vaccine being used

The 2014 outbreak also demonstrated just how important it is to respond quickly.

“It took more than six months for an international response to get up and running after the Ebola outbreak was recognised – and that really was too slow and allowed it to spread all over three countries,” said Jimmy Whitworth, professor of international public health at the London School of Hygiene & Tropical Medicine.

The DRC has a very good record in responding to outbreaks, Whitworth told Al Jazeera, and the national authorities are well set up to deal with the situation, thanks in large part to its past experiences.

The DRC authorities have also approved the use of a new, as-yet unlicensed vaccine to help immunise citizens against Ebola.

“While it alone cannot contain the epidemic, the vaccine plays a very important role in breaking the chain of transmission more quickly,” said Ilunga at the health ministry.

The vaccine, officially named rVSVDG-ZEBOV-GP, was developed and first used in a research setting towards the end of the West African outbreak in 2016, Whitworth explained.

The vaccine takes about 10 days to become protective, and it does not treat people who are already infected with Ebola, but rather, it stops people from contracting the virus. It is being administered to healthcare workers, as well as contacts of people who have been diagnosed with Ebola – and the contacts of those contacts.

As of June 1, the DRC’s health ministry said 809 people have been vaccinated, including 529 in Mbandaka.

Raising awareness

Despite this new development, “the crux of controlling the outbreak” ultimately rests with community awareness, said Gayer.

That happened too late in the 2014 outbreak, where in some cases, “people were aided in escaping, as they called it”, she said. “They saw the treatment centres as a prison. They didn’t understand why they needed to be isolated and treated.”

MSF’s Encinas told Al Jazeera “the Ebola epidemic is accompanied by an epidemic of fear.”

He agreed that raising awareness among vulnerable populations with little understanding or experience dealing with the disease is critical.

Medical teams often have to “start at zero” and must convey basic information about what Ebola is and how it can be treated.

“We need to work together with the community to explain … what is Ebola, how is it transmitted, what the danger is when you have a sick person in your family, what are the impacts for everyone,” Encinas said.

That is especially important in the context of social practices, such as funerals, where hundreds of people may come into contact with a person who died from Ebola.

Ebola can spread through an infected person’s bodily fluids even after that person has died, resulting in what Gayer called “an amplification nightmare” for the contagious disease.

According to Ihekweazu, the biggest challenge with Ebola remains a lack of understanding about the disease and its causes, which then leads to uncertainty about where it will pop up next.

Countries also need to build health networks that will be able to rapidly collect samples and transport them to laboratories for testing.

“Once you get that architecture right, you’ll be in a much better position to detect [Ebola], and once you can detect, you’re in a much better place to mount an appropriate response,” he said.

Still, Ihekweazu said the world is “in a much better place” than it was only a few years ago during the West African outbreak, “in terms of the infrastructure, the people [and] the knowledge about the disease”.

“With every new outbreak, we learn more.”