Democratic Republic of Congo (DRC) declared its tenth outbreak of Ebola in 40 years on August 1, 2018. The latest outbreak was originally centered in the small village of Mangina in North Kivu province, though the epicenter has now moved to the much larger city of Beni.
Latest figures, as of October 27, 2018 (provided by DRC Ministry of Health)
TOTAL CASES: 267
CONFIRMED CASES: 232
CONFIRMED DEATHS: 135
Retrospective investigations point to a possible start of the outbreak in May 2018, around the same time as the Equateur outbreak earlier this year. Though no connection between the two outbreaks can be established, one cannot be 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 in the region, 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 center on July 19 for a heart condition. She was discharged but died at home on July 25 after presenting symptoms of hemorrhagic fever. Members of her family subsequently developed the same symptoms and died soon after. A joint Ministry of Health (MoH)/World Health Organization (WHO) investigation on-site found six more suspected cases, of which four tested positive for Ebola. This result led to the declaration of the outbreak.
The national laboratory (INRB) confirmed on August 7 that the virus spreading in the current outbreak is Zaire Ebola, the deadliest species of the virus and the same one that affected West Africa during the 2014-2016 outbreak that resulted in more than 11,000 deaths. A different strain of the same species was found in the outbreak in Equateur province in western DRC earlier in 2018.
More than ten weeks after the outbreak was declared, it now seems to be reaching a second peak as Beni has seen an increased number of confirmed cases throughout October. Health zones in North Kivu and Ituri provinces (Mandima, Mabalako, Beni, Oicha, Butembo, Kalunguta, Komanda, Masareka, Musienene, and Tchomia) have reported confirmed or probable cases of Ebola. The epidemiological situation in North Kivu is of more concern now than it was in September when the number of cases appeared to be decreasing.
On September 20, a new case emerged in Tchomia, 60 kilometers [about 37 miles] south of Bunia in Ituri province. The infected patient died in Tchomia hospital but was probably infected in Beni and traveled north. The epidemic is now getting very close to the Ugandan border, increasing the risk of spill-over into that country.
Epidemiological teams are still working to identify all active chains of transmission. This is a difficult task, 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 center before being identified as suspected cases and referred to Ebola Treatment Centers.
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 MoH. The contact tracing and follow-up is done by the MoH with a team of epidemiologists.
We don’t have a clear idea of how many unreported deaths have occurred at the community level, especially in villages where people from the larger towns reportedly return when they fall sick.
Mangina, a town of 40,000 people, is in Beni territory in North Kivu province. Beni, the administrative center of the territory, is nearly 20 miles away and is home to about 420,000 people. The area borders Uganda to the east; North Kivu’s capital, Goma, and the Rwandan border are further south. This area sees a lot of trade and traffic, including “illegal” crossings. Some communities live on both sides of the border, and it is quite common for people to cross the border to visit relatives or trade goods at markets on the other side.
The territory is characterized 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 carjackings are very common. Heavy military operations are ongoing.
The city of Beni is subject to military rule, which means traversing some areas in the region is quite difficult and sometimes impossible. Two attacks in Beni—the most recent on October 20—have left a number of people dead and temporarily stopped Ebola outbreak response activities for days.
The outbreak has now spilled into the neighboring province of Ituri, though the majority of cases are still in North Kivu.
Doctors Without Borders/Médecins Sans Frontières (MSF) has run projects in North Kivu since 2006. Today, we have regular projects along the Goma-Beni axis as follows:
Lubero hospital: Pediatric/nutrition care and treatment for victims of sexual and gender-based violence.
Bambu-Kiribizi: Two teams support local the emergency room and pediatric and malnutrition inpatient departments, plus care and treatment for victims 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 the emergency room, emergency surgery, and pediatric nutrition programs.
Goma: MSF runs an HIV program supporting four medical centers (including access to antiretroviral treatment).
Response to the current outbreak
DRC's MoH is leading the outbreak response, with support from WHO. The MoH team dispatched from Kinshasa to coordinate the response in Beni is the same team that coordinated the response in Equateur province. The WHO emergency pool was also mobilized in the area upon the declaration of the outbreak.
Epidemiological surveillance is being set up in both 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 request of the MoH, MSF is part of the task force coordinating the intervention and is focusing on caring for patients affected by the virus, the vaccination of front line 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, more than 100 staff members 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 suspected and confirmed cases in the Mangina health center, the epicenter of the outbreak, where patients were isolated and cared for while a treatment center was built. A treatment center was subsequently opened on August 14, with a capacity of 68 beds that can be extended to 74 if needed. However, it has since been reduced to 24 beds, as the volume of activity in Mangina has dwindled and the focus of the outbreak response has 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 center in a local hospital, followed by an Ebola Treatment Center—jointly operated by MSF and the MoH—on September 20.
As of October 22, MSF had treated 87 patients confirmed to have Ebola and had admitted a total of 314 patients for testing for the virus in Mangina, Butembo, and Tchomia. Of the patients confirmed Ebola-positive in our Ebola Treatment Center, 39 have recovered and returned to their families.
A third Ebola Treatment Center opened on October 12 following confirmed cases in Tchomia, Ituri province, which is near the Ugandan border on Lake Albert. MSF currently supports MoH personnel working in the center with training and technical expertise.
Another isolation center was built by MSF in Beni and handed over to the MoH, who assigned it to another nongovernmental organization. It is now a treatment center.
Health centers in Mangina and Beni that have seen positive cases are being decontaminated. MSF is also involved in these infection prevention and control activities. Furthermore, MSF teams are working in the Beni and Mangina areas as well as in Ituri, between Mambasa and Makeke (on the border with North Kivu), and the Bunia-Tchomia axis, visiting health centers 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 center in Makeke (on the North Kivu-Ituri border), where suspected patients could be isolated and tested for the virus and transferred to Ebola Treatment Centers in Mangina or Beni. The center has now been closed, as the MoH and International Medical Corps opened an Ebola Treatment Center in Makeke.
Further south, MSF sent a rapid response team to Luotu, a village outside of Lubero, on September 9 in response to alerts of a positive case. The team comprised a doctor, a nurse, and a water and sanitation expert and was involved in both case investigation and the construction of a small isolation unit in an existing structure to receive suspected cases.
The positive case patient had spent time in the health center before dying at home, with many of the health center staff, as well as family, considered high-risk contacts. Fortunately, no confirmed cases were registered and the MSF team withdrew on September 27, leaving the structure to the MoH.
Treatment with developmental drugs
In our Ebola Treatment Centers, teams have been progressively increasing the level of supportive care (oral and intravenous hydration, treatment for malaria and other co-infections, as well as treatment of the symptoms of Ebola), and have also been able to offer new therapeutic treatments to patients with confirmed Ebola infection under the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI) protocol. A team of clinicians makes the choice on a patient-to-patient basis between five potential drugs (Favipiravir, Remdesivir [GS5734], REGN3470-3471-3479, ZMapp, and mAb114). These 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 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 MoH and MSF because it is believed they may improve a patient’s chances of survival. 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 that 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 front line workers (health staff, religious leaders, burial workers) from Makeke on the Ituri-North Kivu border up to Biakato. Given that people from Mangina often travel in this direction, it is hoped that this vaccination will help to stop the further spread of the outbreak into Ituri. So far, 360 front line workers have been vaccinated by MSF. On October 18, MSF also started vaccinating front line workers in the city of Beni.
Two MSF teams in Beni support MoH and WHO teams with the screening of local health structures.
MSF health promotion teams in Beni work in support of the infection prevention and control 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.
MSF is also collaborating with the MoH to contribute to the intervention launched in Tchomia (Ituri) in response to new confirmed cases of Ebola.
Our teams in Uganda have also been mobilized in case the outbreak spills over the border. They have set up 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.