A fifth Ebola case has been confirmed in South Kivu province, an area of recent spread, and health officials reported 14 new cases today, putting the overall Democratic Republic of the Congo (DRC) outbreak just shy of 3,000 cases.

In other developments, Doctors Without Borders (MSF) today pushed for two new steps to tackle the outbreak: integrating Ebola care into local health systems and expanding the use of the VSV-EBOV vaccine. And experts advocated for more research on Ebola and breastfeeding, given a lack of clarity that affects recommendations and the risk to babies.

South Kivu cluster expands to 5 cases

In an update today detailing six cases first announced yesterday, the DRC's multisector Ebola response committee (CMRE) said one was in South Kivu province, but there were no details available about the patient. A media report from the DRC said the patient is a 30-year-old man from the affected Mwenga area whose nephew, presumably one of the earlier South Kivu cases, died from Ebola.

The report said the man's symptoms began on Aug 23 and that initially he didn't want to go the Ebola treatment center (ETC), which raises the risk of spread in the community.

The earlier four patients were a mother and child who had been exposed to the virus in Beni, a patient in a health facility where the first patient sought care, and the father of the sick child.

The other 5 cases reported yesterday were in Beni (2), Kalunguta (1), Katwa (1), and Komanda (1), which is in Ituri province. Of the 4 deaths reported yesterday, 2 occurred in the community, 1 in Beni and 1 in Katwa. The 2 others occurred at ETCs in Butembo and Komanda.

Meanwhile, 14 new cases have been confirmed, according to the World Health Organization (WHO) online Ebola dashboard, raising the outbreak total to 2,997. Health officials are still investigating 393 suspected Ebola cases.

Four more people died from their infections, which lifts the overall fatality count to 1,994.

MSF pushes for revised care, vaccine strategy

In an update on the outbreak today, Doctors Without Borders (MSF) said that, more than a year after the outbreak was officially declared, the event is still not under control, despite new tools, including a vaccine and new treatments. The group added that nearly 2,000 people have died and that cases have been detected in new geographic areas.

Though MSF withdrew from its ETCs in Butembo and Katwa, it has expanded its operations in other affected areas. It currently has 10 Ebola projects and, along with the DRC health ministry, is caring for Ebola patients in Goma in North Kivu province, Bunia in Ituri province, and Bukavu in South Kivu province. It is constructing an ETC in the Mwenga area of South Kivu province, the area where the recent cluster of cases was reported.

The group said one of the keys to bringing the outbreak to an end is integrating Ebola response activities into existing health systems to ensure that medical services are close to people who need them. It said people are more likely to seek care at familiar health facilities rather than going directly to an ETC. It also said working more closely with local health centers helps identify cases earlier, which increases the chance of survival and prevents the spread of disease.

MSF also weighed in on the outbreak's vaccination strategy, suggesting that the current ring vaccination strategy isn't enough to contain the epidemic. A drawback of the strategy is that it relies heavily on identification and follow-up on contacts, which is very challenging, the group said. "At least 100-150 identified contacts and contacts of contacts need to be urgently vaccinated around each person confirmed to have Ebola, and this has never been achieved during this outbreak so far," MSF said in a statement.

It said it agrees with expert recommendations that a geographic-based strategy could vaccinate more people who are at risk for contracting the virus. "We have to consider increasing the number of people receiving vaccination against Ebola in the current epidemic as an alternative strategy if we want this potentially game-changing tool to demonstrate real impact," it said, adding that the number of VSV-EBOV doses for the DRC should be increased.

Given concerns about vaccine supply, it said the DRC is reconsidering its decision against adding a second vaccine, Johnson & Johnson's Ad26.ZEBOV/MVA-BN, which requires a follow-up dose.

Concerns about breastfeeding recommendations

In other developments, in a letter to The Lancet yesterday, two experts called for more research on Ebola appearance and persistence in breast milk and better evidence-based advice for asymptomatic breastfeeding mothers in Ebola-affected households. The authors are Mija Ververs, MSc, MPH, with the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health in Baltimore, and Akanksha Arya, MD, with Thomas Jefferson University in Philadelphia.

They said information about Ebola virus presence in breast milk is limited, compared to what is known about the virus in other body fluids, such as urine, blood, and semen. Long-term persistence in breast milk is inconclusive, and Ververs and Arya note that some asymptomatic lactating mothers in Ebola-affected households have been shown to have virus in their breast milk, despite negative blood tests, calling into question guidance that symptomatic mothers and babies who test negative for Ebola should continue breastfeeding.

"We are concerned about these guidelines because Ebola virus blood negativity does not necessarily equal safe breastmilk," they wrote. Aside from duration in breast milk, more research is needed on transmissibility through breast milk, the two added.

They said the consequences from a lack of clarity on the questions are potentially enormous for the DRC, such as eroding public health efforts to encourage breastfeeding or, if the practice is wrongly encouraged for certain Ebola patients, many infants could be at risk. "It is time to give as much attention to Ebola virus in breastmilk as we do in semen," they wrote.

Next response phase, nosocomial infections

In its weekly situation report on the outbreak, the WHO said a small declining trend over the past 3 weeks should be interpreted cautiously, given recent spread to Pinga in North Kivu province and Mwenga in South Kivu province.

The update also highlighted the fourth strategic response plan, which covers the public health response from July through December. It put the price tag at $287 million, which includes $120 million to $140 million for WHO activities.

As of Aug 27, the WHO had received only $45.3 million, though other money has been committed or pledges. It expects that current funding will close the financing gap until the end of September, but more resources are needed from donors to keep the response going through December.

The weekly update had several epidemiologic updates, including, details on nosocomial Ebola cases. Since Jan 1, 11% (321) of Ebola cases are thought to be healthcare-acquired infections. The highest numbers were from Katwa, but since July, Beni has reported the most.

Over the same period, 100 healthcare worker infections were reported, roughly 5% of all cases. Katwa has had the most, but, as with nosocomial infections, since July, greater numbers have been reported from Beni (7), with Mandima reporting 6.

An analysis of the healthcare infections suggests that they are more likely to occur at the smallest facilities, and the DRC's infection prevention and control commission is working on a system to investigate and address issues at health centers that are linked to possible nosocomial infections.

See also:

Aug 27 CMRE update

Aug 27 Kivu Avenir story

WHO online Ebola dashboard

Aug 28 MSF press release

Aug 27 Lancet letter

Aug 27 WHO Ebola situation report