Democratic Republic of Congo (DRC) declared their tenth outbreak of Ebola in 40 years on 1 August 2018. The outbreak is centred in northeastern North Kivu province. With the number of cases surpassing 300, it is now the country's largest-ever Ebola outbreak.
Latest figures - information as of 18 November 2018; figures provided by DRC Ministry of Health
366 TOTAL CASES
319 CONFIRMED CASES
167 CONFIRMED DEATHS
Retrospective investigations point to a possible start of the outbreak back in May – around the same time as the Equateur outbreak earlier in the year. There is no connection or link between the two outbreaks.
The delay in the alert and subsequent response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (there are limitations on movement, and access is difficult) and a strike by the health workers of the area which began in May, due to non-payment of salaries.
A person died at home after presenting symptoms of haemorrhagic fever. Family members of that person developed the same symptoms and also died. A joint Ministry of Health/World Health Organization (WHO) investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak.
The national laboratory (INRB) confirmed on 7 August that the current outbreak is of the Zaire Ebola virus, the most deadly strain and the same one that affected West Africa during the 2014-2016 outbreak. Zaire Ebola was also the virus found in the outbreak in Equateur province, in western DRC earlier in 2018, although a different strain than is affecting the current outbreak.
So far, 14 health zones in North Kivu and Ituri provinces have reported confirmed or probable cases of Ebola. They are:
More than three months after the outbreak was declared, the epicentre has moved from the town of Mangina to the much bigger city of Beni, where the number of confirmed cases showed a clear increase in October.
The fact that many of the new cases are not linked to any previously known chains of transmissions is a concern, as it makes it more difficult to trace contacts and control the evolution of the outbreak. Moreover, the number of cases keeps increasing in the Ebola Treatment Centre (ETC) of Butembo, a city three times bigger than Beni in terms of inhabitants. Most patients however are ‘imported cases’, from health zones outside of the city.
Another reason for concern is the geographically scattered pattern of the outbreak. The epidemic is very close to the Ugandan border, increasing the risk of a spill over into that country. The government of Uganda has started a vaccination campaign targeting 3,000 front line workers as a preventive measure. The South Sudanese government announced the enhancement of its Ebola-related capacities, and some Rwanda Red Cross staff have attended a safe and dignified burial training.
Epidemiological teams are still working on identifying all active chains of transmission. This is not simple given that the local community in the affected areas is highly mobile and moves from village to village for work and family reasons, as well as to seek healthcare. Sick people have been known to visit more than one health centre before being identified as suspect cases and referred to an Ebola Treatment Centre.
Mangina, a town of 40,000 people, is in Beni Territory, North Kivu province, northeastern DR Congo. Beni, the administrative centre of the territory, is about 30 kilometres away and is home to about 420,000 people. The area borders Uganda to the east; the North Kivu capital Goma, and the Rwandan border are further south. This area sees a lot of trade, but also traffic, including “illegal” crossings. Some communities live on both sides of the border meaning that it is quite common for people to cross the border to visit relatives or trade goods at the market on the other side. The region is densely populated, and the Ugandan border is a sensitive area and is crucial in terms of developments of the outbreak spreading in the region.
The territory is characterised by high levels of insecurity – it is considered an area of conflict, with over 100 armed groups estimated to be active in North Kivu. Kidnappings and carjacking are very common. It is an area of heavy ongoing military operations – the city of Beni is subject to military rule and military justice, and moving around some areas in the region is quite difficult and sometimes impossible. Attacks in Beni have left a number of people dead, and have forced Ebola outbreak response activities to temporarily stop for a number of days before resuming.
Since October, the epicentre of the outbreak has moved to Beni. Butembo, located 1.5 hours by car to the south of Beni, is a city of about 1 million people, which is also seeing new confirmed cases every week. The outbreak has spilled in to the neighbouring province of Ituri, but the majority of cases still occur in North Kivu.
EXISTING MSF PRESENCE IN THE AREA
MSF has had projects in North Kivu since 2006. Today, we have regular projects along the Goma-Beni axe as follows:
Lubero hospital: paediatric/nutrition care and treatment of sexual and gender-based violence. Bambu-Kiribizi: Two teams support local emergency room and paediatric and malnutrition in-patient departments, plus care and treatment of sexual and gender-based violence. Rutshuru hospital: MSF withdrew from the hospital at the end of 2017. However, in light of the volatile conditions in the region, we have returned to support emergency room, emergency surgery and paediatric nutrition programmes. Goma: HIV programme supporting four medical centres (including access to antiretroviral treatment).
The response to the current outbreak
The DRC Ministry of Health (MoH) is leading the outbreak response, with support from WHO. The MoH team sent to coordinate the response in Beni was dispatched from Kinshasa and is the same team that coordinated the response in Equateur province. The WHO emergency pool was mobilised in the area upon the declaration of the outbreak.
At the Ministry of Health’s request, MSF is part of the national strategic group coordinating the intervention on several pillars of the response:
- Caring for patients affected by the virus in ETCs (Mangina, Butembo, Tchomia), and people who are suspect cases (Beni, Bunia);
- Communication and health promotion in communities;
- Vaccination of frontline workers;
- Infection prevention and control (IPC): protecting local health structures (and their workers) by helping with screening patients at the entrance, hand and foot disinfection, capacity for short-term isolation of suspect patients, and decontamination of the facilities where confirmed Ebola patients have transited;
- Training staff;
- Supporting surveillance activities.
In total, more than 100 MSF staff members are currently working in Ebola projects in North Kivu and Ituri. This excludes MoH personnel working in MSF structures, in order to keep a clear distinction between MSF and MoH in our public communication.
Our first task was to improve an isolation unit for suspect and confirmed cases in the Mangina health centre, the epicentre of the outbreak, where patients were isolated and cared for whilst a treatment centre was built. A treatment centre was subsequently opened on 14 August, with a capacity of 68 beds, but it has since been reduced to 24 beds as the volume of activity in Mangina has dwindled and the focus of the outbreak shifted to other areas.
Butembo, a town estimated to be home to one million people, has seen imported cases from Beni. We responded immediately, setting up an isolation centre in a local hospital, followed by a second Ebola Treatment Centre – jointly operated by MSF and the Ministry of Health – on 20 September. This ETC opened with a capacity of 32 beds (12 beds for confirmed and 20 for suspect cases), but an extension of the ETC has just been completed, and will allow the teams to increase the capacity of the structure to a total of 64 beds.
A third ETC was opened on 12 October following the appearance of confirmed cases in Tchomia, Ituri Province, on Lake Albert (on the Ugandan border). This treatment centre was handed over to the MoH on 5 November, following an extended period with no new cases being reported. We supported Ministry of Health personnel working in the centre by providing training, logistic support and technical expertise.
During the first week of November, we opened a new isolation centre on the premises of the General hospital in Bunia, Ituri. The centre has a hospitalisation capacity of 16 beds, as well as a screening point at the entrance (with more than 2,000 people screened each day), and a small isolation unit for suspect cases.
Another isolation centre was built by MSF in Beni and handed over to the Ministry of Health, who assigned it to another NGO, Alima – it is now a treatment centre. On 14 November, we opened a transit centre for suspect cases in Beni. The new transit centre is located approximately 200 metres from the existing ETC supported by Alima. Confirmed cases are transferred by ambulance from the transit centre to the ETC; those who turn out to be negative are referred to other health structures in the area, to facilitate their access to care for other health problems.
Our teams also built a seven-bed transit centre in Makeke (on the North Kivu-Ituri border), where suspect patients could be isolated and tested for the virus and transferred to Ebola Treatment Centres in Mangina or Beni. The centre has now been closed because the Ministry of Health and International Medical Corps opened an Ebola Treatment Centre in Makeke.
Infection prevention and control
In addition to patient care in ETCs, we are active in several pillars of the Ebola response. Health centres in Mangina and Beni that have seen positive cases are being decontaminated – we are also involved in these infection prevention and control activities.
Furthermore, our teams work in the Beni and Mangina surrounding areas as well as in Bunia, Ituri, visiting eight health centres and training staff on the proper triage of Ebola suspects, as well as setting up isolation areas in case of need and providing material for all these activities.
Rapid Response Team
One of the critical components of the Ebola response is the ability to react quickly to new alerts, being able to investigate them and decide on setting up new structures for the intervention. For this, MSF set up a Rapid Response Team composed of a doctor, a nurse, a water and sanitation expert, a health promoter, and an epidemiologist.
Further south in North Kivu, on 9 September we sent this rapid response team to Luotu, a village outside of Lubero, in response to alerts of a positive case. The team was not only involved in case investigation but also in building a small isolation unit in an existing structure to receive suspect cases.
The positive case had spent time in the health centre before dying at home, leaving many of the health centre staff, as well as family members, as high-risk contacts. Fortunately, no confirmed cases were registered and we withdrew our team on 27 September, leaving the structure to the Ministry of Health. The same team was deployed to Tchomia when the first confirmed case appeared there.
Treatment with developmental drugs
In our ETCs, MSF teams have been progressively increasing the level of supportive care (oral and IV hydration, treatment for malaria and other coinfections as well as treatment of the symptoms of Ebola) and have also been able to offer new potential therapeutic treatments to patients with confirmed Ebola infection under the MEURI protocol. A team of clinicians makes the choice on an ad-hoc basis between five potential drugs (Favipiravir, Remdesivir (GS5734), REGN3470-3471-3479, ZMapp, and mAb114). The treatments are given only with the informed consent of the patient (or a family member if they are too young or too sick to consent) and are provided in addition to the supportive care.
These five drugs have not passed clinical tests yet and we are unable to measure their efficacy - yet their utilization has been approved by the ethical committees of the Ministry of Health and MSF, because it is believed they may improve a patient’s chances to survive. While caution must be exercised, these treatments are an added resource to the response. Because of their untested status, their utilization is subject to a strict protocol which places particular emphasis on the informed consent of the patient. Discussions on the implementation of a proper clinical trial are ongoing.
We have vaccinated 480 frontline workers (health staff, religious leaders, burial workers, etc) from Makeke on the Ituri-North Kivu border up to Biakato, as the population from Mangina often moves in this direction. In October our teams also vaccinated 606 people, being either health workers or potential contacts of confirmed Ebola patients, in the city of Beni. In November, we have vaccinated 150 health workers in Butembo, with the plan to vaccinate 1,700 people.
The surveillance strategy is led by the MoH/WHO. One MSF epidemiologist in Beni and one in Butembo support surveillance activities.
Our health promotion teams in Beni work in support of the infection prevention and control teams and vaccination teams, as these activities require intensive communication with the community. The health promotion teams are also in contact with local leaders of several health zones, to exchange information about Ebola and the community. We also run health promotion activities around the ETCs in Butembo and Mangina, in Bunia (Ituri).
Our teams in Uganda have also been mobilised to be ready in case the outbreak spills over from across the border. They have installed an isolation tent in Bwera, a small town directly over the border from Beni and Butembo. MSF's non-emergency project in Hoima (Uganda) has also set up an isolation tent.
In South Sudan, we are supporting the government in preparations for a possible outbreak in the country.
All MSF projects in North Kivu and Ituri areas have been supplied with Ebola equipment, including personal protective equipment (PPE), and have put proper hygiene and infection control protocols in place to safeguard staff and patients from the risk of contamination, should the epidemic spread further.
We remain ready to support the authorities of these – and other – neighbouring countries in the implementation of their response to the Ebola outbreak in DRC.