The current Ebola outbreak in Democratic Republic of Congo (DRC) is the worst on record in the country and the second-largest epidemic of the disease recorded anywhere. Almost a year-and-a-half after the declaration of the outbreak, it is still not under control, and more than 2,200 people have died from the virus.

On July 17, 2019, the World Health Organization declared the Ebola outbreak in DRC a public health emergency of international concern, and it continues to pose a threat to local communities despite a massive international response promising new vaccines and treatments and improvements in the medical management of the disease.

In recent months, efforts to contain the outbreak were further hindered by the volatile security situation and an increase in violent attacks against medical facilities, personnel, and patients. In 2019, there were more than 300 attacks on Ebola health workers, resulting in six people killed and 70 wounded.

Ebola situation report as of January 13:

Total cases: 3,388

Total deaths: 2,233

Survivors: 1,224

Cases of Ebola have been reported in North Kivu, Ituri, and South Kivu provinces, with the current hotspots located in North Kivu province: Mabalako, Kalunguta, and Butembo.

The Ministry of Health officially declared the outbreak on August 1, 2018, but it likely began months earlier. This is the tenth outbreak of Ebola in DRC in 40 years and by far the country's largest on record. It is also the second-largest Ebola epidemic ever in any country, behind only the West Africa outbreak of 2014–2016.

While the rate of transmission appeared to slow in November—averaging 10 new cases per week compared to September’s weekly average of 40 new cases—in the second week of December, when violence intensified, the number of new cases increased rapidly to 24. In the second half of December, the number of new cases stabilized and decreased to 14 per week, but the outbreak remains a serious public health concern.

Over the last month, new cases were reported in five health zones that were no longer considered places of active transmission (meaning at least 42 days without a reported Ebola case): Biena, Butembo, Katwa, Kalunguta, and Mambasa.

Out of 13 health areas currently reporting active transmission, more than half of the confirmed patients in December were from Aloya health area in Mabalako health zone. On December 3, a 24-year-old man in Aloya—who survived Ebola in June—tested positive again for Ebola and died. Lab tests confirmed his death was due to a resurgence of the disease and not reinfection. Forty-five positive Ebola cases were directly linked to this case, one of whom was identified in Butembo, which had not reported a case for 55 days. This highlights how essential proper follow-up and close monitoring of survivors are, even after they are discharged from treatment centers.

The Doctors Without Borders/Médecins Sans Frontières (MSF) Ebola response

MSF is an active player in the Ebola response, caring for patients in two Ebola treatment centers (ETCs) in Beni and Goma, as well as numerous decentralized isolation and transit facilities where people with suspected cases of Ebola are tested before going to a treatment center if needed.

MSF also supports infection prevention and control (IPC) in local health care facilities and vaccination activities in the region. Our main priorities are assessing community health needs, providing timely health care to Ebola patients, ensuring appropriate IPC standards in health care facilities, and improving access to and quality of non-Ebola-related health care.

In all our projects, we put patients and communities first and engage with local people and existing health centers to identify needs and prioritize activities. In addition to integrated isolation and treatment facilities for suspected Ebola patients, MSF also strengthens health care capacities; builds infrastructure for clean water, sanitation, and hygiene; and invests in community outreach and health messaging in health centers across the region.

A dangerous increase in violence

At the end of 2019 and the beginning of 2020, an increase in military operations and a series of violent attacks by armed groups spurred protests in several towns in North Kivu province—the epicenter of the outbreak. Since November 20, daily demonstrations against the United Nations have become more violent: Dozens of people have died and approximately 250 people were violently attacked.

Fighting between armed groups as well as targeted violence limits crucial health activities like vaccination, surveillance and contact tracing, community health promotion, and safe burials in some areas, including Ebola hotspots such as Beni, Biakato, and Mangina.

In the last week of November, only 376 people were vaccinated, compared to an average of 3,000 people per week in October in the Biakato mine region. In Mangina, surveillance continued at the community level, but surveillance and coordination by the Ministry of Health (HoH) and World Health Organization (WHO) stopped.

Three aid workers were murdered, and several Ebola responders were injured during violent attacks in the Biakato Mines region on November 27 and 28. As a result, the majority of health care personnel were evacuated or left and contact tracing, vaccination, and referrals either slowed down or were stopped. On December 4, MSF temporarily withdrew its staff from the Biakato Mines region after receiving multiple threats.

MSF was not directly targeted by armed groups but was also forced to temporarily or permanently evacuate all or some of our teams as a result of increased violence in Beni, Mabalako, and Mayuano.

Presence of armed forces

While it is paramount that health care providers and their facilities be respected, it is equally important that health care providers work to truly earn the trust of the communities they seek to serve. MSF insists that the actions of law enforcement must be distinct from the public health response and that this distinction must be clear to local communities. Linking the Ebola response to security forces only creates further risks for both the local population and humanitarian actors, and only serves to further alienate communities and erode people’s support of the response.

At the end of December, MSF ended medical activities in Biakato due to the deployment of armed forces around and within health structures. “We are aware that a solution is needed to ensure the protection of the civilian population and the safety of medical personnel after the tragic events of November,” Ewenn Chenard, MSF emergency coordinator, said in a statement announcing the closure. “However, we firmly believe that military presence in health facilities undermines the neutrality and impartiality of medical aid. It is essential that health structures remain free of weapons so that communities feel safe to come and seek care.”

MSF is concerned about further discussions to reinforce existing security mechanisms by deploying teams of military medics, using armed escorts for responders (during surveillance and vaccination activities), and reinforcing the presence of armed forces in medical facilities. Communities in Ebola-affected areas have repeatedly objected to the presence of security forces in Ebola-related activities. Building trust with communities affected by the outbreak should be at the center of the response and dependence on security forces must be dramatically reduced.

People on the move

Thousands of people have been displaced across North Kivu due to the recent deteriorating security situation. For example, in the Kalehe region, in South Kivu, the increase in military operations against local armed groups caused the displacement of thousands of people. This movement increases the risk of a geographic spread of the disease—especially when health controls, such as monitored points of entry, along roads are reduced or stopped due to violence and unrest.

In Lwemba, in Mandima health zone in Ituri province, there is a strong opposition to all Ebola-related activities. Following the death of several people suspected to have Ebola in mid-November, more than 60 family members of those who had died left the town. They moved to a surveillance camp in Bundji, in the Beni health zone, to seek protection from the disease. Since then, 17 positive cases with epidemiological links to Lwemba have been reported in three different health zones: Mandima, Mabalako, and Beni. This shows how limited access to health care forces people—even high-risk contacts of Ebola patients—to travel to seek care elsewhere in the country and inadvertently contribute to the spread of the virus to new areas.

Key challenges

Ending the Ebola outbreak remains a complex endeavor. While fewer people have been confirmed to have Ebola in recent weeks, the epidemiological data show that further efforts are needed to improve the response. New Ebola patients are confirmed with an average delay of five days from the onset of symptoms to diagnosis—a time in which they are infectious to others and miss out on the benefits of receiving early treatment that would improve their chances of survival.

The percentage of new Ebola cases that were not previously listed as contacts doubled from the week of November 18 (14 percent) to the following week (30 percent), with similar figures observed in the first two weeks of December—week 49 and 50—(27 percent and 29 percent, respectively).

The new treatments for confirmed Ebola patients available in ETCs are used under a study protocol framework that does not allow access beyond a particular patient or health worker. Extended use, like for additional protection for high-risk contacts, is not currently supported by the protocol. While confirmed patients and health workers benefit from the medication, their overall use remains restricted.

Persistent fear and misconceptions about Ebola treatment facilities and vaccination activities in local communities pose an additional challenge. One-third of all deaths have occurred in homes and communities where treatment was not available and people weren’t properly isolated to minimize the risk of spreading the disease.

Community engagement

Putting communities and patients first—and treating patients as people, not biological threats—is crucial to ending the epidemic. Community dialogue and engagement must form the cornerstone of the Ebola response.

For many communities across the affected region, the Ebola outbreak is only one of several pressing medical concerns. Of patients admitted to Ebola transit and treatment centers with symptoms like fever, vomiting, or diarrhea, only 4 percent have tested positive for Ebola, while the rest have other health needs.

And Ebola is not the only public health emergency in DRC. The main causes of mortality in the country’s eastern region remain preventable diseases such as malaria and measles. DRC’s measles epidemic has spread to all 26 provinces of the country and is now the largest outbreak of measles in the world. More resources must be urgently committed to target areas where the outbreak is still raging. In many health zones, only limited health care is available, as was the case even before the Ebola epidemic.

Many health workers have also now been recruited away from hospitals and health centers across the region by the internationally funded and well-paying Ebola response elsewhere. The staff shortages and a lack of financial resources and medical supplies for non-Ebola medical needs threatens to further weaken the health system and lower communities’ acceptance of the Ebola response.

A substantial amount of resources has been invested in the Ebola response since the beginning of the epidemic. MSF strongly encourages actors and donors to consider the wider needs of the population rather than focusing response efforts on Ebola alone. Where communities ask for health care services for illnesses other than Ebola, their needs must be taken seriously and an appropriate response implemented alongside, or sometimes even before, direct Ebola-response actions. Several MSF projects have adjusted their approach based on lessons learned since the outbreak began.

In all our Ebola emergency and regular projects in the region, MSF is committed to planning, implementing, and evaluating activities with input from the communities we serve. MSF projects start with an open community dialogue exploring needs and assessing what MSF can do to meet those needs.

Ebola vaccines

The Merck vaccine is estimated to offer effective protection for 97.5 percent of participants ten days after vaccination and is a promising tool in the fight to contain the outbreak.

However, due to the limited use and investigational status of this vaccine, until recently the vaccination strategy was limited to a “ring approach.” This meant only contacts of people who are likely to or have been confirmed to have Ebola and their contacts—plus frontline workers like doctors and humanitarian staff who are most likely to interact with people who have Ebola—are eligible to be vaccinated.

MSF supports the Strategic Advisory Group of Experts’s (SAGE) recommendations to begin geographic vaccination, use pop-up sites, and expand vaccination activities. Recently, the MoH and WHO obtained a waiver from Merck to use 30,000 doses of the Ebola vaccine “out of the investigational protocol.” This new approach would resemble a “routine vaccination” where doses are administered to the entire community in certain hotspots more efficiently and using fewer resources. But there have been delays in both bringing additional vaccine stocks into the country as well as defining and communicating the plan on what areas to target.

At the same time, a second experimental vaccine produced by Johnson & Johnson requiring two doses given 56 days apart has been greenlighted in DRC as part of an extended clinical trial, and MSF and its medical research arm Epicentre are part of the global consortium leading the rollout. The preparation phase has started in two health districts of Goma. The vaccines arrived in DRC on October 31, and the rollout began on November 14. But for several days now, unrest in Goma has halted the rollout in several sites.

Post-Ebola

The Ebola outbreak is not over yet. The dynamics of the epidemics have been unpredictable, with recurring reports of new cases in areas that had not registered them for many weeks, showing that further efforts are needed to avoid a resurgence of transmission.

The epidemic has severely destabilized the already fragile health care system. The medical needs of the population extend well beyond Ebola, as demonstrated by the ongoing measles epidemic that has claimed more lives than Ebola. Predictably, a phasing-out of Ebola intervention will have a far-reaching impact on this situation, so discussions on the steps required once the outbreak has ended should start now and consider the manifold health needs of the population.