Ebola poses vexing challenge six months after latest outbreak

Ebola poses vexing challenge six months after latest outbreak
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An outbreak of the deadly Ebola virus in two eastern provinces of the Democratic Republic of Congo is growing in a large urban center where residents are distrustful of outside health officials, posing a massive challenge to national and international responders racing to contain the disease.
For six months, the Ebola virus has raged through North Kivu and Ituri provinces, along Congo’s border with Uganda and Rwanda. It is now the second-worst Ebola outbreak in modern history, infecting 774 people, according to Congo’s health ministry.
Of those infected, 481 have died.
The outbreak began in a tiny rural village in the northern part of North Kivu Province and quickly spread to Beni, a city of about a quarter-million residents. From Beni, the disease spread north into Ituri Province, then south to the much larger city of Butembo.
“In a sense, what we’ve had is a series of linked brush fires, some of them quite intense,” said Mike Ryan, a veteran Ebola hunter at the World Health Organization (WHO).
More recently, the virus has spread to and within Katwa, an urban area next to Butembo where residents live in dense conditions along the hills that adjoin the two cities. In recent weeks, dozens of new cases have popped up in Katwa, most of whom have not sought treatment.
The Ebola virus is most contagious in the very last stages of life, when a victim carries the highest viral load. Those who do not seek treatment risk infecting family members who care for them and wash bodies for burial; the majority of infected patients in recent outbreaks contracted the virus from a deceased family member.
Doctors Without Borders, one of the main nongovernmental organizations responding to the outbreak, opened an Ebola treatment center in Butembo in November. The group opened a second center in Katwa on Jan. 3. That facility opened with space to care for 16 patients; by the end of this week, it will have enough space to care for 70 patients.
Responders said the outbreak is worsening in Katwa because of a deep mistrust that residents in the area, members of the Nande tribe, hold against outsiders, including their own government based in far-off Kinshasa. 
“It’s an area that has not known an Ebola outbreak before. They do not know the disease, so it’s a big challenge for us to make sure people understand what the signs are, what they need to do,” Pierre Van Heddegem, who is coordinating the local response for Doctors Without Borders, said in an interview from Katwa. “You need the trust of the community, and without that you’re nothing. And we’re very far from that right now.”
North Kivu has been riven by ethnic violence for decades. Of the province’s estimated 8 million residents, about a million are internally displaced. More than 20 armed rebel groups operate in the region, undermining security and threatening the effectiveness of the response. 
A bombing in Beni in September killed nearly two dozen people, an attack claimed by the largest of those groups, the Allied Democratic Forces. Responders say they hear gunfire on a regular basis, and a World Health Organization official had to be evacuated for medical treatment after being attacked last month.
Ryan said the security situation in Katwa and Butembo is better than in Beni. The local militias allow health responders to operate, though residents do not always accept outside help.
“We have seen communities react to the presence of teams with stone throwing and more. And that unsettles teams and makes for a difficult situation,” Ryan said. “We’ve had real challenges in community engagement, particularly in Katwa, and it’s been very difficult to penetrate in the communities and have them fully participate in the response.”
The largest number of transmissions of the Ebola virus have come in three of Katwa’s 18 health areas. International responders from WHO, Doctors Without Borders and groups like UNICEF are flooding resources into those health areas, Ryan said, in hopes of stamping out the virus before it spreads again.
The added scrutiny has allowed health officials to find and identify more cases.
“The number of alerts has risen very dramatically, which on the one hand could be seen as a bad thing, but it’s also a good thing,” Ryan said. “It means we’re getting to the roots of the virus at the community level.”
Teams of health workers are piecing together evidence of the transmission chains, a crucial step that allows responders to identify where the virus came from, and where it might head next. The number of victims who do not seek treatment, and therefore stay hidden from health workers, has muddied that critical process.
Ebola is “still not under control right now. There are too many cases popping up right now that we cannot link to previous cases, which is a problem. If we can link them to previous cases, that gives you some indication that you're doing it right,” Van Heddegem said. “Most problems that we see are in neighborhoods where there is still incomprehension towards what the response really is.”
Global health officials have deployed a vaccine that appears to be working. More than 72,000 people in Congo have received the vaccine in recent months, the health ministry said Sunday. And because the region borders other nations, health officials including Americans from the Centers for Disease Control and Prevention have been preparing front-line health workers in Uganda, Rwanda and South Sudan for the possibility that the virus could jump across international boundaries.
That spread has not happened yet, but health officials said it remains a possibility. But the spread of Ebola throughout Katwa is the region’s most pressing concern.
“Katwa is the biggest threat we face right now. It has the most intense transmission. We’re making progress in the community. We’re making progress with surveillance, but there’s more work to be done,” Ryan said. “This is as complex as it gets.”