Ebola in the DRC: One Year, 2000 deaths and counting

Ebola in the DRC: One Year, 2000 deaths and counting
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In recent days the Ebola outbreak in the Democratic Republic of the Congo (DRC), though only occasionally meriting headlines in American newspapers, achieved a new milestone: The death toll has now surpassed 2,000 and the case count stands over 3,000. 

If this outbreak, which has been designated by many experts as the most difficult and complex Ebola outbreak in history, continues to simmer along uninterrupted as it has for over a year, the DRC is facing the real threat of endemicity, a chronic continual transmission of Ebola. 

Were this to occur, even though Ebola would not find high income countries hospitable, the biosecurity of the world would be severely diminished. 

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Ebola: The history

Ebola is a well-known and well-characterized virus that first was discovered in the 1970s after back-to-back dramatic outbreaks in Africa. It is a virus that is deadly, scary, but not usually very contagious as it requires exposure to blood and body fluids to transmit.

It is magnitudes lower in contagiousness than measles. After an up to 21 day incubation period, it causes many symptoms including fever, muscle aches, rash and diarrhea, but in later stages of the illness it can lead to the dysfunction of multiple organ systems which can lead to shock and death.

About half of patients may have bleeding manifestations which is why it is known a hemorrhagic fever virus. The mortality rate is about 60-70 percent with supportive care. Its natural reservoir is bats and it has the capacity to spill into other species including primates. 

Since its appearance in 1976, the virus has caused over two dozen outbreaks that were mostly small, easily contained and located in rural parts of central African countries. Relatively simple, routine public health interventions are what stopped Ebola outbreaks. 

These tasks including finding cases, isolating them, creating places where Ebola patients could be cared for safely, changing burial practices; and providing gowns, gloves and surgical masks. 

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This historical experience, in retrospect, led to an under appreciation of the difficulties that would emerge in controlling the 2013-2014 West African Ebola outbreak. 

This was the largest Ebola outbreak on record. It led to importations of Ebola to several countries (including the United States in which 2 nurses were infected) and left three countries decimated by this small virus. 

What fueled this outbreak, however, was not some new attribute acquired by the virus, but a severe distrust of public health authorities by the impacted communities making public health interventions extremely difficult.

Ebola in the DRC

The current DRC outbreak — the 10th in the country — is mainly situated in two provinces, Ituri and North Kivu. These provinces are plagued with marauding militias who continually battle in an anarchic state of affairs. One militia, the Allied Democratic Forces (ADF), is allegedly aligned with ISIS. Not only do these militias make the terrain treacherous for intervention, they have actively targeted healthcare workers and centers

Coupled to this insecurity, which has kept many responders out of the outbreak zone, is a lack of community engagement — and even violent opposition — to public health interventions. Reports of Ebola being a myth, being created by the West and other similar rumors have made the work of containing this outbreak very difficult. 

Though the outbreak has been largely confined to these two states in the DRC, it has been able to spread across the border to Uganda on two occasions with cases being diagnosed there. More concerning was spread to a more populous city in the DRC, Goma, a factor that led the World Health Organization (WHO) to declare a public health emergency of international concern (PHEIC) which has led to the devotion of increased resources to the outbreak.

Recent days have seen cases in another state, South Kivu, as well. Countries that border the DRC have been proactively (and wisely) preparing for the disease crossing their borders as well. 

New tools

Unlike the majority of Ebola outbreaks in the past, this outbreak has seen extensive use of several new tools. An experimental vaccine, shown to be highly effective, has been used in over 200,000 individuals at risk for Ebola and a second experimental vaccine is to be added. Employing a technique that was successful in eradicating smallpox, contacts of cases are being ring vaccinated to form prevent further spread. 

However, the success of ring vaccination is entirely premised on identifying cases and their contacts, a feat that can be difficult without full community engagement. 

The fact that the outbreak is still persisting, despite the hundreds of thousands of vaccine doses administered, illustrates that a shadow epidemic, shielded from the eyes of public health authorities (evidenced by deaths in the community and cases occurring in people not identified as contacts), is occurring despite vaccination efforts. 

Undoubtedly, the outbreak would be much larger without the vaccine, but it will not stop while a scrumptiously spreading shadow epidemic, unreachable by the vaccine and public health interventions, is occurring. 

In addition to the vaccine, experimental antibody therapies (mAb114 and REGN-EB3) targeting the virus have shown remarkable results in diminishing the rate of death in those who are treated early in the course of disease. To benefit maximally from such therapies, it is necessary that individual cases be found and brought to Ebola treatment centers.

No silver bullet

There are no easy answers to stopping this outbreak as its complexity doesn’t lend itself to a silver bullet solution. No vaccine or antiviral can carry the burden alone. What is needed is the ability to perform basic public health functions free from violence. 

This includes a redoubling of efforts to engage the community and educate them about the threat of Ebola, its symptoms, how it spreads, how it is treated, the power of the vaccine and myriad other questions that might arise. This formula has stopped every Ebola outbreak in history — and it can stop the current outbreak — but only if adequate resources, expertise and attention are directed at to this precarious situation.

Dr. Amesh Adalja M.D., is a board-certified in infectious disease, critical care medicine, emergency medicine and internal medicine physician. He is a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA.