Democratic Republic of Congo has seen multiple outbreaks of Ebola, but this time it faces more challenges.

It is the worst Ebola outbreak to have struck the Democratic Republic of Congo (DRC) – and the most complex one.

Since August, authorities in the country, together with a host of partners, have been trying to contain a new outbreak of the disease in the eastern North Kivu and Ituri provinces.

As of November 21, there have been 373 suspected cases of Ebola, including 347 confirmed cases. At least 217 people have already died.

There have been 10 outbreaks of Ebola since 1976 in the DRC, which is considered among the most experienced in dealing with the virus.

The situation this time, though, is different.

The North Kivu and Ituri provinces are among the most unstable and densely populated in the country, and subject to some of the highest levels of human mobility in it.

At the same time, there are warnings that a “perfect storm” of insecurity, community resistance about vaccinations and political manipulation threatens the efforts to contain the spread of the virus.

These factors collectively make the latest outbreak unlike anything the DRC, which is scheduled to hold a crucial presidential election on December 23, has experienced before.

What is Ebola and how does it spread?

The Ebola Virus Disease (EVD) is introduced into the human population through close contact with the blood or other bodily fluids of infected animals. These include, but are not limited to, monkeys or fruit bats.

The virus is known to cause high fever, vomiting and diarrhoea, as well as internal and external bleeding; it puts the body into a state of shock and results in a decrease of the perfusion of blood to vital organs, ultimately inducing multi-system organ failure.

Once infected, patients have a very low chance of surviving.

When did the latest outbreak in the DRC begin?

In late July 2018, the provincial government of North Kivu reported 26 cases of acute haemorrhagic fever that had resulted in 20 deaths.

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Six specimens of blood were sent to the Institut National de Recherche Biomedicale (INRB) in the capital, Kinshasa, where four samples tested positive for the Ebola virus.

“The result of the genetic analysis by INRB confirmed Ebola Zaire strain, but not linked to the Equateur outbreak strain, meaning that we are dealing with a new outbreak,” Lianne Gutcher, a communications officer with the World Health Organization (WHO), told Al Jazeera.

The country’s Ministry of Health officially declared an outbreak on August 1, 2018.

The centre of the outbreak is now Beni in North Kivu, though the medical charity Doctors Without Borders, also known by its French initials MSF, has warned that there is a possibility it could move to Butembo, a town close to neighbouring Uganda.

How does this outbreak compare with previous ones in the DRC?

Ebola is considered endemic in the DRC, with the first cases in 1976 appearing simultaneously in Yambuku – in the north of the country near the Ebola River, from which the disease takes its name – and Nzara, in what is now South Sudan.

While there is still no cure, the introduction of a vaccination programme earlier this year has been touted as the next step towards a more effective management of future outbreaks.

The DRC has been hit by two outbreaks this year.

The first one was declared in May after the deaths of 29 people in the city of Mbandaka in the Equateur province. Though there were concerns the town’s proximity to the Congo River would see the virus moving to Kinshasa, the timely implementation of a vaccination drive saw the virus quickly contained.

That outbreak was announced over on July 24.

Both Uganda and the DRC have been able to prevent mammoth epidemics spreading as it did in West Africa between 2014 and 2016 that infected 28,000 people and caused 11,300 deaths. But given that the current outbreak in North Kivu is perhaps the first time the virus has spread into an area already home to a large-scale humanitarian crisis, containing the spread of Ebola this time around is proving to be a lot more difficult.

It is already the largest outbreak in the DRC and is on course to become the second largest Ebola outbreak ever.

“The difference is that we are now operating in a war zone,” Axelle Ronsse, the emergency coordinator for MSF’s Ebola response, told Al Jazeera, referring to the militia violence that has long plagued parts of the country’s east.

How has the security crisis impacted efforts to contain the virus?

North Kivu is home to a number of armed groups, including the Allied Defence Forces (ADF), a Ugandan rebel group, that has operated with impunity since 1995.

The endless upheavals in the region have meant regular dispossession and the incessant movement of refugees to neighbouring countries or within the province itself. As it stands, there are more than a million internally displaced people in North Kivu.

“The violence impacts our work on a daily basis,” Ronsse says. “We are not targeted but it is a matter of being in the wrong place at the wrong time.”

Likewise, Gutcher, from the WHO, says that some attacks have resulted in medical activities being severely impeded or temporarily shut down.

“Community violence has also at times impeded the work of safe burial teams’ ability to conduct safe and dignified burials.”

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In October, rebels killed 13 civilians and kidnapped a dozen children in an assault on Beni.

In November, seven Malawian and one Tanzanian peacekeeper were killed in another attack on the town.

The instability has also made it difficult for health professionals to locate others who might have been in contact with suspected victims, in what is known as “contact tracing”, considered a basic pillar of any effort to contain Ebola.

Last month, The New England Journal of Medicine (NEJM) wrote that “carrying out the effective contact tracing and community engagement can permit rapid identification of people who are ill and facilitate the provision of early clinical care, which has been shown to improve the likelihood of survival.”

Jessica Ilunga, communications officer for the DRC’s Ministry of Public Health, told Al Jazeera that every security-related incident affected field activities. She added that the underlying security context had also created a climate in which health workers faced an unprecedented level of community resistance.

“The predominance of traditional healers, who are more trusted by the population than modern medicine, has also led to an important number of nosocomial transmissions of the virus,” Ilunga said.

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Citing the instability in the eastern DRC, the WHO elevated the national crisis to “very high” in late September. The crisis is still not considered a public health emergency of international concern and the world health body does not recommend imposing any trade or travel restrictions with the DRC.

How have the DRC and the international community responded to this crisis?

Since the introduction of the vaccination programme by the DRC’s government and the WHO, a key intervention has involved vaccinating suspected patients and then administering a second “ring” to those who might have come into contact with these suspected cases.

The vaccine is Canadian-developed but licensed and produced by the American pharmaceutical company Merck.

According to the WHO, around 300 medical specialists have been deployed to the country to support the response plan. Around 32,500 people-at-risk have been vaccinated, including 10,600 health workers and 8,600 children.

On November 24, the government and the WHO said they would be conducting clinical trials to assess the safety and effectiveness of drugs used on Ebola patients to find the most effective treatment for the virus.

Authorities have already started using the drugs on a case-by-case basis on around 151 people. Those who used the drugs had a 63 percent chance of survival, while those who did not receive medication had a fatality rate close to 80 percent.

“Now that protocols for trials are in place, patients will be offered treatments under that framework in the facilities where the trial has started,” the WHO said.

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Over and above vaccinations and drugs, efforts have been made to spread information through door-to-door advocacy, with more than 2,500 homes visited, including almost 1,400 homes in Beni alone.

“Faced with rumours and misinformation, some families have chosen to care for sick relatives at home; some patients leave healthcare centres to find alternatives or actively avoid follow up,” Gutcher says.

Authorities have also trained around 1,700 volunteers to assist with community-based efforts. Across the border in Uganda, 758 health workers in 19 health facilities have been vaccinated.

In mid-November, the WHO said that the outbreak would end in mid-2019.

But Ilunga, from the DRC’s Ministry of Public Health, says her government is hopeful that the efforts to contain the outbreak would succeed sooner than the WHO’s target, but concedes that “the success of this response also depends on a number of factors that we do not control, such as security”.

A health worker carries a four-day-old baby suspected of having Ebola, into a Doctors Without Borders-supported Ebola treatment centre in DRC [File: John Wessels/AFP]

Why do outbreaks continue to occur in the DRC?

Microbiologists argue that viruses such as Ebola often occur among animal populations faced with restricted movement.

However, health professionals are concerned that should the Ebola become endemic to the troubled areas in the northeastern DRC, it would mean “a sustained and unpredictable spread of the deadly virus, with major implications for travel and trade”.

“This will mean that we’ve lost the ability to trace contacts, stop transmission chains and contain the outbreak,” Tom Inglesby, director of the Johns Hopkins Center for Health Security, said in a briefing earlier in November.

For her part, Ilunga says the country needs to accept the fact that the disease “will resurface regularly” and “make preventive and curative treatments more available and improve the population’s knowledge about the virus”.