The numbers from the Democratic Republic of Congo continue to indicate that even though the country has become experienced in responding to outbreaks of Ebola — the 10th since the virus was identified — is likely to be the most challenging to control.
On Aug. 20 the World Health Organization (WHO) reported that of the 96 known cases, at least 13 are health-care workers.
Moreover, 125 health-care workers are under surveillance as contacts of patients with Ebola. In addition, the WHO African Regional Office reported that of the total 1,609 identified contacts, “On 18 August 2018, 954 (59%) contacts were successfully followed Contacts in Mandima Health Zone were not followed up for an apparent community resistance.”
Follow up of contacts must be much higher than 59 percent to stop an Ebola outbreak from becoming a widespread pan-epidemic as in 2013-2016 in West Africa.
The DRC Ministry of Health reported a further challenge to stopping this outbreak in an August 19 update, noting that 41 contacts were in the “red zones” where security risks prohibit outside surveillance teams from entering.
But these numbers are just one indication of the consequences when resources, staffing, security and infrastructure fall short of what is needed on the ground.
Like West African and international health-care workers who provided direct hands on care to Ebola patients during the pan-epidemic in 2013-2016, I do not have to try to remember the tragedy, the faces of our patients, the children, the parents, the grandparents because it is not something one can forget.
The cause of death for most patients with Ebola is not hemorrhage, as sometimes portrayed in movies or books. Instead, most deaths are caused by extreme dehydration and shock caused by vomiting, diarrhea, and profuse sweating.
This sweating is due to fever, the weather, and the tents or hospital wards where patients are treated, especially if the tents are small, have no temperature control, fans, or even air circulation. These were conditions I worked in with many patients and colleagues in 2014 in Sierra Leone and Liberia. Unlike treatment for patients in the U.S., life-saving rehydration was not available for thousands of patients. And why not?
There were none of the laboratory tests we consider routine in the U.S., no radiologic tests, no breathing machines or kidney dialysis machines. In Monrovia, Liberia when we were overwhelmed in October 2014, and patients young and old died every day and every night, Liberian health-care workers introduced a way for life-saving oral rehydration solution to be given to the patients too weak to drink it by themselves by patients who were already strong enough to care for themselves. We called this curative (not-palliative) approach “the stronger help the weaker.”
More than 800 of our West African health-care worker colleagues were infected and more than 500 died of Ebola. Much like this ongoing outbreak in the DRC, initially Ebola was not suspected when the patients sought care for an illness that could understandably be confused with malaria, dysentery, cholera, or others.
Ebola has never been reported in this area of northeast DRC. With no reason initially to suspected Ebola and to take appropriate precautions, even if they had been available, these health-care workers were highly vulnerable, some were infected, and therefore at risk of transmitting the virus to their families, co-workers and other contacts.
Even if Ebola-specific Personal Protective Equipment was available from the beginning of an Ebola outbreak there must be repetitive training on how to appropriately put on this Ebola-PPE and how to safely remove it after providing patient care.
The protective layers of Ebola-PPE induce profuse sweating before one is done putting it on, and thus the amount of time one can work with patients is agonizingly short. As soon as our thick rubber boots filled up with our own sweat, often within 45 minutes of going in to help our patients, then we knew it was time to leave before we became too dehydrated for our own safety.
In contrast to the lost months at the start of the West Africa outbreak, DRC health officials and international responders are responding swiftly to this one. In an admirable response to the major obstacle that red zones present to identifying and breaking further chains of transmission of the virus, health officials were able to have 15 of the 41 contacts travel out of the red zone into the city of Beni where they can be observed and offered the promising, but unlicensed, Merck Ebola vaccine.
Efforts to follow the remainder of these 41 contacts in these red zones are occurring via daily telephone coordination with health center and community workers inside the red zones. Importantly, however, the Ebola vaccine cannot be offered inside these red zones. If symptomatic cases occur among persons in these red zones, identifying and treating these patients and preventing new chains of transmission in order to stop this Ebola outbreak will become an extreme challenge.
A fulcrum point may soon be reached in terms of whether Ebola can be stopped once again in the DRC, for the 10th time since 1976, or whether it will spread more than ever before in the DRC and to one or more of its nine neighboring nations.
As a precaution, the WHO African Regional Office emphasized August 20 that it has prioritized four of these neighbors — Burundi, Rwanda, South Sudan, and Uganda “to enhance operational readiness and preparedness.”
Although 1,273 at-risk persons have received the Ebola vaccine between Aug. 8-19, much more vaccine will be needed if this outbreak spreads within the DRC and into any of its neighbors.
The greatest need, however, continues to be for readiness everywhere — to overcome whatever obstacles present themselves wherever Ebola, or the next pathogen with pan-epidemic potential might emerge, to detect, prevent, track and treat the disease immediately, effectively and with equity.
Daniel Lucey M.D. MPH, is an infectious diseases physician and adjunct professor of infectious diseases at Georgetown University Medical Center, a senior scholar at the Georgetown University O’Neil Institute and a member and spokesperson for the Infectious Diseases Society of America.