Throughout last year, an outbreak of the Ebola Virus Disease (EVD) in the eastern provinces of the Democratic Republic of the Congo (DRC) made the Ministry of Health declare the tenth epidemic on 1 August. Although initially it was located in the area of Manguina and Beni, in the North Kivu province, across the year it slowly expanded to the province of Ituri and other neighbouring territories such as Butembo and Katwa, where it spread on a large scale to become the second Ebola epidemic in history after the outbreak that befell West Africa in 2014. Far from relenting, new cases continued to mount this year, until, on 17 July 2019, the World Health Organisation (WHO) declared it an “International Emergency”.
The “International Emergency” declaration was made after the first case was confirmed in Goma, a city bordering Rwanda and, with two million inhabitants, the access route to the rest of the country and an international connection. The WHO Emergency Committee issued a call for international funding to strengthen the response and stressed the need to protect the livelihoods of those most affected by the outbreak, keeping transport routes and borders open.
At the time of writing this article, there are over 3,100 registered cases and 2,100 deaths, representing a death rate verging on 70%. The epidemic is out of control and has affected 213 health care areas out of the region’s 471, spreading to South Kivu and crossing, on two occasions, the Uganda border. Data show a higher impact among women, 58% of which make up the total number affected, while children under five represent 14%, a figure that is doubled to 28% of cases when it includes children up to the age of 18. Survivors of the disease are also exceptional cases, with physical complications confirmed on account of the virus’ capacity to remain in some organs or be transmitted sexually, affecting, in some instances, mental health.
Apart from the community spread of EVD, a high rate of nosocomial infections, with an average of 11%, has been recorded since the start of the epidemic, although at the time of writing it has reached a peak of 20%. Consequently, we can see a decrease in the use of services in health centres and, by contrast, an increase in the demand for home health care, with an increased risk of infection in the community sphere. As a result, the impact on health workers, who make up 5% of the people affected by EVD, is considerable.
As well as the serious physical consequences of the disease, there are also psychosocial problems caused by the epidemic. Fear, frustration and despair lead to higher levels of stress in people affected, impacting ill people, their families, orphaned minors or those separated from their families, contacts, people suspected of suffering from the disease and survivors. Response actors, such as staff in Treatment Centres or Transit Centres, professionals in health centres and all intervention teams, are also experiencing psychosocial effects. We can consider, therefore, that the whole community suffers the consequences of the impact of this devastating disease.
There are a number of factors that make controlling the epidemic difficult. For a start, the population’s reluctance to take measures to prevent transmission, such as the rejection of a diagnosis, which turns them into people suspected of having the disease, isolation until the diagnosis is confirmed, or pessimism over tests in Transit Centres or treatments in Ebola Treatment Centres (ETCs) far from their homes. This refusal increases in the case of having to decontaminate the homes of people affected or Health Centres, burials without correct rituals, contact tracing or the fear of vaccination.
Moreover, certain communities also repudiate response actors, primarily governmental intervention teams, who are viewed with suspicion, and health care agencies and NGOs — national and international — working in the area. This rejection intensifies when response actors move around communities protected by security services or when ETCs and deployed facilities are protected by the military or armed forces from the United Nation’s Stabilisation Mission in the DRC (MONUSCO).
Another determining factor is the lack of security in the zone: a large number of armed groups have been active for many years, which stops epidemiological surveillance groups and epidemic prevention and control teams from operating safely in the zone. There are regular attacks on these teams and even Treatment Centres, despite security.
Furthermore, the widespread movement of people from the areas affected by the epidemic to other regions in the DRC, and even crossings through the porous borders to neighbouring countries, is causing an increased risk of the disease spreading to other geographical areas.
The conflict perpetuated over dozens of years and insecurity is behind a fragile public health care system, which in turn is conditioning the control of the epidemic, as is a limited and precarious network of health care centres.
The above is also exacerbated by conditions of under-development in extensive rural areas without running water, drainage and with a lack of electricity, causing unfavourable hygiene conditions that make the epidemic spread more easily.
Nevertheless, in contrast to previous epidemics, on this occasion there is a vaccine. Under the name rVSV-ZEBOV and manufactured by Merck laboratories in phase IV trials, it is being used in the current epidemic outbreak. With a ring vaccination strategy, some 200,000 people affected by EVD, their families, contacts and response actors, have been vaccinated. The initial results of the evaluation demonstrate a high protection rate against the disease with 95% effectiveness.
Another available treatment comes in the form of pharmaceutical drugs against the virus. The trial study PALM “Together Save Lives” is a WHO initiative set up during the epidemic to evaluate the safety and effectiveness of these medicines in ETCs. Of the four initial treatments, two of them — REGN-EB3 and mAb114 — are yielding positive results, providing a greater chance of survival for those receiving them.
There are numerous challenges, however, and undoubtedly the geographical spread of the disease poses a challenge in terms of the effective organisation and coordination by the Ministry of Health, which is leading the response, and the co-leadership of the WHO and UNICEF, together with other UN agencies and NGOs. The fourth strategic response plan to the EVD epidemic (SRP4) constitutes a key tool for guaranteeing coordination.
Another challenge to deal with is the availability of resources. The operationalisation of the response requires essential resources to implement certain activities, particularly those related to care work in health centres, which need better levels of hygiene, infrastructures and equipment provisions to develop preventative measures and control infections, in addition to training for health care staff. The current financial requirements are estimated, in the period stretching from July to December 2019, to rise to 287 million dollars, half of which is lacking at the present time.
With regard to vaccination, although the ring vaccination strategy is producing encouraging results, the target population should be extended to all high-risk groups. Another major challenge is related to survivors of the disease, who require care and a monitoring of their somatic state and mental health over time, which in turn requires the development and implementation of comprehensive programmes that effectively deal with the needs of this collective.
Most of all, and despite promising therapeutic measures and rehabilitation programmes, the most effective strategies continue to revolve around preventative measures based on strengthening public health care. To attain this in a way that is both effective and sustainable, there must be decisive backing of development in the region.