Democratic Republic of Congo (DRC) declared their tenth outbreak of Ebola in 40 years on 1 August 2018. The outbreak is centred in the town of Mangina, in the northeastern North Kivu province.
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. Although no connection between the two outbreaks can be established, it cannot ruled out either.
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.
The initial alert came after a woman from Mangina was admitted to the local health centre on 19 July for a heart condition. She was discharged but died at home on 25 July, after presenting symptoms of haemorrhagic fever. Members of her family subsequently developed the same symptoms and also died soon afterwards. 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.
More than ten weeks after the declaration of the epidemic, we seem to be facing a second peak of the outbreak: the epicentre has now moved from the small village of Mangina to the much bigger city of Beni, where the number of confirmed cases has shown a clear increase throughout October. Ten health zones in North Kivu and Ituri provinces (Mandima, Mabalako, Beni, Oicha, Butembo, Kalunguta, Komanda, Masareka, Musienene and Tchomia) have so far reported confirmed or probable cases of Ebola. The epidemiological situation in North Kivu is more of a concern now than it was in September, when the number of cases appeared to be decreasing.
On 20 September, a new case emerged in Tchomia, 60 km south of Bunia in Ituri province. The infected patient died in Tchomia hospital, but was probably infected in Beni and travelled all the way up north. The epidemic is now getting very close to the Ugandan border, increasing the risk of a spill-over into the country.
Epidemiological teams are still working on identifying all active chains of transmission. This is not simple given that the local communities in the affected areas are highly mobile and move from village to village for work and family reasons, as well as to seek health care. 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.
Since the beginning of the outbreak more than 8,000 contacts have been identified and more than 2,732 are currently being followed up by the Congolese Ministry of Health. The contact tracing and follow-up is done by the Ministry of Health with a team of epidemiologists.
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. Two attacks in Beni - the most recent on 20 October - have left a number of people dead, and have forced Ebola outbreak response activities to temporarily stop for a number of days before resuming.
The outbreak has spilled in to the neighbouring province of Ituri, but the majority of cases still occurs 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.
Epidemiological surveillance is being set up both in North Kivu and Ituri provinces and a laboratory for testing is fully operational in Beni (previously every sample was sent to Kinshasa). Other partners are involved in water and sanitation, health promotion and community outreach activities.
At the Ministry of Health’s request, MSF is part of the task force coordinating the intervention and is focusing on caring for patients affected by the virus, the vaccination of frontline workers, as well as protecting local health structures (and their workers) by helping with triage, decontamination and training. MSF is also supporting surveillance activities.
In total, over 100 staff are currently working in MSF’s Ebola projects in North Kivu and Ituri provinces.
MSF's 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. MSF responded immediately, setting up an isolation centre in a local hospital, followed by an Ebola Treatment Centre – jointly operated by MSF and the Ministry of Health – on 20 September.
As of 22 September, MSF had treated 74 patients confirmed to have Ebola and had admitted a total of 195 patients for testing for the virus in Mangina and Butembo. Of the patients confirmed Ebola-positive in our Ebola Treatment Centre, 33 have recovered and returned to their families, while 5 confirmed patients and 8 suspect patients remained under treatment.
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). MSF is currently supporting the Ministry of Health personnel working in the centre by providing training and technical expertise.
Another isolation centre was built by MSF in Beni and handed over to the Ministry of Health, who assigned it to another NGO – it is now a treatment centre.
Health centres in Mangina and Beni that have seen positive cases are also being decontaminated – MSF is also involved in these infection prevention and control activities. Furthermore, there are MSF teams working in the Beni and Mangina areas as well as in Ituri, between Mambasa and Makeke (on the border with North Kivu), and Bunia – Tchomia axes, visiting health centres and training staff on the proper triage of Ebola suspects, as well as setting up isolation areas in case of need.
MSF 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.
Further south, MSF sent a rapid response team to Luotu, a village outside of Lubero, on 9 September in response to alerts of a positive case. The team was composed of a doctor, a nurse and a water and sanitation expert and was not only involved in case investigation, but also in building a small isolation unit in an existing structure to receive suspected cases. The positive case had spent time in the health centre before dying at home, with many of the health centre staff, as well as family, considered high-risk contacts. Fortunately no confirmed cases were registered and MSF withdrew our staff on 27 September from this centre, leaving the structure to the Ministry of Health.
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.
MSF is also vaccinating frontline workers (health staff, religious leaders, burial workers ,etc) from Makeke on the Ituri-North Kivu border up to Biakato. Given that the population from Mangina move often in this direction, it is hoped that this vaccination will help to stop the infection spreading further into Ituri. So far, 360 frontline workers have been vaccinated by MSF. On 18 October we have also started vaccinating frontline workers in the city of Beni.
Two MSF teams in Beni support the teams of the MoH and WHO, who decide on the strategy of this pillar. Our teams screen local health structures.
MSF health promotion teams in Beni work in support of the IPC teams and vaccination teams, as these activities require intensive communication with the community. The HP teams are also in contact with local leaders of several health zones, to exchange information about Ebola and the community.
MSF is also collaborating with the Ministry of Health to contribute to the intervention launched in Tchomia (Ituri) in response to new confirmed cases.
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.
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.