By early February 2019, transmission of Ebola in the Democratic Republic of the Congo's (DRC's) Ituri province was largely under control, and declines were observed in Katwa and Butembo, several leading experts on the outbreak wrote yesterday in the New England Journal of Medicine (NEJM).

But a sudden increase in violent attacks on healthcare workers and facilities throughout North Kivu province have caused the outbreak to spike in the last 2 months and become intractable.

The experts, including DRC Minister of Health Oly Ilunga Kalenga, MD, and the World Health Organization (WHO) African regional director, Matshidiso Moeti, MD, published a special report on the 10-month-long outbreak, the world's second largest.

"Numerous operational challenges posed by chronic insecurity are compounded by political tensions associated with contested national elections. Violence has increasingly been targeted at EVD response teams and facilities, exacerbating the spread of the virus," they said.

Today, Reuters reported that 26 members of a rebel group thought to be linked to the Islamic State were killed near Beni in a shootout with DRC military. The rebels are part of the Allied Democratic Forces, but the Islamic State is also claiming responsibility for the attack, which was directed against the Congolese army.

Need for political will to end outbreak

The authors of the NEJM report said though the outbreak officially began on Aug 1, 2018, in Ituri province, cases likely date back to April of that year. This was the first time Ebola was recorded in this part of the DRC, and most residents had never heard of the virus before: Malaria, diarrhea, and childhood diseases were the common illnesses among communities.

Nosocomial transmission likely played a large role in early transmission. Though the outbreak was quickly contained in Ituri province within 1 month, infected people traveling to Beni, Butembo, and Katwa, brought the disease to those locations.

Violence is what has allowed Ebola to continue. The authors produced a graph that shows how major times of unrest in the outbreak region have been followed by increased Ebola transmission, including a massacre in Beni, violent protests after the DRC's recent presidential election, and February's burning of Ebola treatment centers.

The authors concluded by saying that all the tools of outbreak control are in place, including an effective vaccine, surveillance means, and growing community engagement. But without political will, the outbreak will go on.

"The alignment of key political and armed groups behind the response effort is essential to stop the violence against health care and rehabilitate the humanitarian space required for outbreak control," the authors said.

Total now 1,945 cases, including 2 newly infected health workers

Yesterday the DRC's ministry of health confirmed 19 new cases of Ebola, raising the outbreak total to 1,945, including 1,302 deaths.

Fifteen new deaths were recorded yesterday, and 297 suspected cases are still under investigation. Of the 15 newly recorded deaths, 10 occurred in the community, which raises the risk of transmission.

There are now 108 health workers infected with the virus, including two newly diagnosed workers from Kalunguta and Mabalako. Both had been vaccinated. Thirty-six health workers have died during this outbreak.

Vaccination efforts continue, with a total of 126,565 people reached as of yesterday.

Lessons from West Africa outbreak

Yesterday in the Lancet, authors from the Ebola Gbalo Research Group published an article outlining lessons learned during the response to the Ebola outbreak in Sierra Leone in 2013-2015.

Community engagement was the key, they suggested, for successful response efforts.

"Burial teams and contact tracing worked best when the recruits were local," the authors wrote. "Where local agents, including health personnel, government workers, and families, were strongly involved in planning and implementing the response it was more effective."

See also:

May 29 NEJM report

May 30 Reuters story

May 29 DRC report

May 29 Lancet article