The Democratic Republic of Congo (DRC) was still grappling with the country’s largest Ebola outbreak when a new 11th outbreak took hold in June. But the current outbreak, located in the country’s west, looks quite different from its record-setting predecessor: the virus appears to be spreading more slowly, producing small clusters in isolated areas, and has a lower mortality rate.
But why is this outbreak so different from the country’s previous experiences? How has the medical response evolved, and how can we take advantage of the experience gained through previous outbreaks?
Dr Guyguy Manangama, medical and operational lead for Ebola activities with Médecins Sans Frontières (MSF) discusses the situation in DRC.
You’ve recently visited Équateur province, the heart of the 11th outbreak—what can you tell us about this epidemic?
The eleventh Ebola outbreak in DRC was declared on 1 June 2020. Since then, 130 people have fallen ill and 55 have died from the disease. The first cases were reported in the town of Mbandaka, Équateur’s administrative centre, before small clusters began to appear in the more peripheral districts. Since then, the outbreak has been advancing at a slow pace. Although the situation appears to be under control, experience shows that new clusters can still occur.
At the same time, we are observing significantly lower levels of viral loads and mortality compared to the tenth Ebola outbreak, which struck the east of the country between 2018 and 2020. Mortality is still high at 43 per cent today, but it’s down from the 67 per cent we saw during the tenth outbreak in North Kivu and Ituri provinces.
A possible explanation is that some sort of natural immunity exists among people in Équateur province, as this region has experienced Ebola outbreaks before, most recently in 2018. Reservoirs of the virus are traditionally present there. It is possible then that some people may have experienced low-level exposure to the virus before and may be immune in some way. This is just a hypothesis based on observations; further analysis is needed. We are also benefitting from the scientific progress made in recent years, including our ability to use a vaccine, and curative treatments that have proven to be effective in clinical trials conducted during the previous outbreak in North Kivu.
What are the main differences you have seen between the tenth and eleventh outbreaks, and how do these differences affect our activities?
The previous epidemic was exceptional in many ways—it took place in an area which had never seen the disease before, and was located in an area under conflict. The outbreak currently underway is quite different.
We don’t see large urban clusters, but instead see sporadic cases that don’t appear to spread in a linear way. This is related to the geography of the area—without major long-distance roads. communities move along the meandering waterways of the area as they go from one small village to another. This means that patients are scattered over a vast area that includes 12 of the 17 health districts in the province.
How are the tools developed during the last outbreak helping in the current Ebola response?
The Ebola vaccine was deployed early in the current outbreak and may have played an important role in reducing the spread of the virus. The vaccination strategy is prioritises vaccinating people who have had direct or indirect contact with the sick, but in rural and sparsely populated areas it is often more expedient and effective to vaccinate the entire community, which results in a higher level of protection.
After some delays, the new treatments have also been rolled out in treatment centres. These tools allow for a radical change in approach—while limiting the circulation of the Ebola virus remains a very important objective for the response, efforts are now increasingly focused on patient care and recovery. Previously, we could do little more than isolate the sick and provide them with symptomatic treatments. Having curative treatments at our disposal means that the patient and the quality of care can take centre stage.
One of the main challenges during the 10th outbreak was people’s reaction to the arrival of the response teams. What is the relationship like with the community in Équateur province?
Our work in northeastern DRC was surrounded by a very violent conflict. In Équateur, the environment is much calmer. The good relationship between healthcare personnel and local people can also be attributed to the new approach, which is based on empowering decentralised micro-structures for Ebola care in local healthcare facilities, close to patients and communities, and limiting the use of large, centralised facilities.
We support the local healthcare network to identify, isolate and treat patients with Ebola disease, minimising the need for a parallel system. We promoted this approach as early as in 2019, while tackling the previous outbreak in the east. It has now been adopted by all those involved in the medical response, including the Ministry of Health, and has many advantages.
Large treatment centres are neither appreciated by communities nor easily accepted by patients and their families; they are hermetically sealed and impenetrable—they spark fear. By having the option of being treated closer to home, in facilities that are known and accessible to their families, patients are much more willing to come forward in case of symptoms. If they are indeed infected with Ebola, early admission to care also increases their chances of recovery. When sending our mobile teams, we have also taken into account the broader health needs of people aside from Ebola; this has also greatly contributed to the good acceptance of our teams by communities.
Although this deadly virus is very serious, it is at last beginning to look like a treatable—and, through vaccination, preventable—disease, rather than a biological threat.