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Ebola

In the Democratic Republic of Congo, we are currently responding to the second-worst Ebola outbreak in history

Ebola is one of the world’s deadliest diseases.

It is a highly infectious virus that can kill up to 90 percent of the people who catch it, causing terror among infected communities.

Ebola is so infectious that patients need to be treated in isolation by staff wearing protective clothing.

DRC Ebola outbreak, 2018-19

Map of MSF Ebola activities in northeast DRC

Ebola has now killed more than 2,100 people in the Democratic Republic of Congo (DRC) as the outbreak in the northeast of the country continues.

With over 3,300 cases, this is the second-worst Ebola outbreak in history – following the 2014 West Africa epidemic. 

On 1 August 2018, we began responding to an outbreak in North Kivu province in the northeast of the country – a region recently characterised by violence and instability – marking the first time that MSF has faced an Ebola outbreak in an active conflict zone. The epidemic has since spread to the neighbouring provinces of Ituri and, most recently, South Kivu.

On 17 July 2019, the World Health Organisation officially declared the current outbreak "a public health emergency of international concern".

MSF is adjusting its response to target the evolving hotspots and is currently supporting the Ebola response through patient care in four Ebola Treatment Centres, numerous decentralized isolation/transit zones, and infection prevention and control, and vaccination activities.

While some projects have been closed and others have been downsized, MSF teams are setting up new activities in Ituri. These include opening a 17-bed Ebola Treatment Centre in Biakato at the request of the Ministry of Health and after consultation with the community.

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Urgent action is needed

The Ebola outbreak in eastern DRC continues to be a serious public health concern despite a reduction in the number of confirmed Ebola cases reported each week.

During the first eight months of the epidemic, around 1,000 cases of Ebola were reported. However, this rate soon increased dramatically.

In July 2019, between 80 and 100 people were diagnosed with the disease each week, while Uganda reported its first Ebola patients who had travelled from DRC in June.

Fortunately, the rate of known transmission is slowing, averaging 18 new cases a week in October 2019 compared to September’s weekly average of 40 new cases.

In total, 70 new Ebola cases were identified during the month of October, compared to 157 in September.

Out of the nine health zones in north-eastern DRC that reported cases, most were between Biakato in Ituri province and Mangina and Beni in the North Kivu province, which are at the centre of the current transmission.

The risk of flare-ups in former hotspots remains high as shown by the new cases in Beni at the end of October.

“We must place local communities at the heart of the emergency response. All organisations must work together in this direction to put an end to this terrible outbreak.”

Tristan Le LonquerMSF emergency coordinator

“As the number of people killed by the Ebola outbreak in the DRC passes 2,000, this is a grim reminder that, after more than one year, the Ebola response is failing to tackle the epidemic,” says Tristan Le Lonquer, emergency coordinator in North Kivu.

“Despite having new treatments and an experimental vaccine, all of which have proven effective, communities are still not on board and continue to express hostile sentiments towards the response. They won’t support the Ebola response if their most basic non-Ebola healthcare needs are being ignored.

“We must place local communities at the heart of the emergency response. All organisations must work together in this direction to put an end to this terrible outbreak.”

Violence against healthcare

Insecurity in the region is still a significant challenge for the Ebola response, as northeast DRC has been an area of active conflict for the past quarter-century and is rife with armed groups.

Alongside this, healthcare workers associated with the Ebola response are still not trusted by the community. They have been specifically targeted, sometimes forcing crucial activities such as contact tracing or vaccination campaigns to be suspended, limited or cancelled.

MSF was forced to leave Katwa and Butembo in February 2019 after violent attacks on Ebola treatment centres.

On 17 October 2019, the health centre in Lwemba where MSF was just starting to support activities was partly burnt down. The two sites built by MSF weren’t targeted, however, as of 18 November, MSF had not resumed its activities in Lwemba and talks between communities and stakeholders still ongoing.

On 2 November 2019, a radio journalist employed as a community worker for the Riposte was murdered in Lwemba. 

community trust

Ending the Ebola outbreak remains a complex endeavour. While fewer new cases are being reported, there is still, on average, a five-day delay between the onset of symptoms and a patient being admitted to care.

During this time, they are not only infectious to others but miss out on the benefit of early treatments, which can increase their chance of survival.

However, neither the fear induced by this highly lethal, little-understood disease, nor the pre-existing tension in the area can explain the inability of organisations to win the local population’s support. Instead, the overall approach of all involved has to be questioned and improved.

Part of this includes integrating Ebola treatment into existing local healthcare centres rather than creating a "parallel system" of facilities that are shrouded in mystery and seen by the community as places where people go to die.

MSF was already working in this volatile region long before the current Ebola epidemic – responding to recurring violence, endemic malaria and outbreaks of measles or cholera. However, the massive mobilisation of resources associated with this Ebola response marks a striking contrast to the neglect this region has suffered from over the decades.

This has added to the widespread belief that the priority of many organisations is not in the best interests of the community. 

The Ebola response must urgently adapt to the needs and expectations of the population if we are to gain control of the epidemic. 

  • Humanitarian organisations involved in the Ebola response must engage with the communities, listen to them and understand their needs in terms of health care. Ebola isn’t the only public health emergency in DRC. The main causes of mortality in eastern DRC remain preventable diseases such as malaria and measles, but in many areas, health care is limited. The narrow, Ebola-centric approach initially adopted by the intervention was one of the main reasons of the response’s failure to earn the trust of the very communities it is trying to serve.
  • Respect for patients is fundamental. Ebola patients, suspect and confirmed, should be cared for and respected like any other patient, not treated as biological threats. This means giving them a choice based on informed consent at all stages of care and avoiding coercion or pressure.
  • MSF works with communities and has adapted its approach to their needs and expectations. We have extended our support to general health care in health centres and hospitals across the region, investing in primary and secondary healthcare together with Ebola-related activities. 

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Vital vaccinations

MSF joins the calls of many experts who recommend expanding the use of the current vaccine.

The Merck vaccine is estimated to offer effective protection for 97.5 percent of patients 10 days after vaccination and is a promising tool in the fight to contain the Ebola outbreak.

As of 17 November 2019, over 253,000 people have received the vaccine so far through “ring vaccination” – an approach that targets people who have had contact with confirmed Ebola patients, as well as frontline workers.

However, successful contact tracing has proved notoriously difficult in DRC and MSF supports recommendations to expand vaccination activities to cover the entire population that is at risk.

Such steps are needed urgently if we are to prevent the epidemic from lasting another year.

At the same time, a second experimental vaccine produced by Johnson & Johnson has been given the green light in DRC as part of an extended clinical trial and MSF is part of the global consortium leading the rollout.

As of 17 November 2019, the start date of vaccination activities was yet to be confirmed. 

Multiple health crises

Despite some positive signs, it remains unknown when the Ebola epidemic will end.

The current Ebola epidemic that claimed 2,196 lives so far has severely destabilized the healthcare system.

Importantly, the medical needs of the population extend well beyond Ebola, as demonstrated by the ongoing measles epidemic that has claimed more lives than Ebola.

A phasing-out of Ebola intervention will have a far-reaching impact on this situation so discussions on the steps required for a Post-Ebola management should start now and consider the multiple health needs of the population.

For many people, the main concern is not Ebola, but how to obtain care for their children who are dying of measles and other illnesses, as well as how to find shelter from the unrest.

All these needs, including Ebola, are public health risks that must be responded to.

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West Africa Ebola outbreak, 2014-16

The Ebola outbreak in West Africa killed 11,315 people after being officially declared on 22 March 2014 in Guinea.

During the Ebola emergency, 28 of our staff members caught Ebola. Fourteen recovered but 14 died.

The vast majority of these infections were found to have occurred in the community.

On 22 December 2016, the results of an experimental Ebola vaccine trial were released by the Lancet. The trial found the vaccine to be highly effective in protecting people against the Zaire strain of Ebola.

“This vaccine will be a powerful tool to help prevent the spread of the Zaire strain of Ebola and to protect health workers," said MSF President Dr Bertrand Draguez. 

"MSF will try to make use of it in any future outbreak of the disease. More research is still needed to determine the length of protection that it offers to people and into vaccines for other strains of Ebola. Progress also still needs to be made in improving the treatment of patients once they are infected with Ebola, to make sure more lives can be saved.”

Ebola management: interactive guides

Hover over the image below for an interactive guide to Ebola

Prior to the 2014 outbreak, it is estimated there had been over 1,800 cases of Ebola, with nearly 1,300 deaths.

Ebola history

The Ebola virus was first associated with an outbreak of 318 cases of a haemorrhagic disease in Zaire (now the Democratic Republic of Congo [DRC]) in 1976. Of the 318 cases, 280 died — and died quickly.

That same year, 284 people in Sudan also became infected with the virus, killing 156.

There are five different strains of the Ebola virus: Bundibugyo, Ivory Coast, Reston, Sudan and Zaire, named after their places of origin.

Four of these five have caused disease in humans. While the Reston virus can infect humans, no illnesses or deaths have been reported.

Before the 2014 outbreak, MSF had treated hundreds of people affected by Ebola in UgandaRepublic of Congo, DRC, Sudan, Gabon and Guinea

In 2007, MSF entirely contained an epidemic of Ebola in Uganda by placing a control area around the treatment centre.

What causes Ebola?

Ebola can be caught from both humans and animals. It is transmitted through close contact with blood, secretions, or other bodily fluids.

Healthcare workers have frequently been infected while treating Ebola patients. This has occurred through close contact without the use of gloves, masks or protective goggles.

In areas of Africa, infection has been documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found dead or ill in the rainforest.

Burials where mourners have direct contact with the deceased can also transmit the virus, whereas transmission through infected semen can occur up to seven weeks after clinical recovery.

Hear more stories from our staff on the MSF podcast, Everyday Emergency

Symptoms of Ebola

Early on, symptoms are non-specific, making it difficult to diagnose.

The disease is often characterised by the sudden onset of fever, feeling weak, muscle pain, headaches and a sore throat. This is followed by vomiting, diarrhoea, rashes, impaired kidney and liver function and, in some cases, internal and external bleeding.

Symptoms can appear from two to 21 days after exposure. Some patients may go on to experience rashes, red eyes, hiccups, chest pains, difficulty breathing and swallowing.

MSF UK doctor Javid Abdelmoneim reflects on his time battling Ebola in Sierra Leone in this powerful and painful TEDxAthens talk 

Diagnosing Ebola

Diagnosing Ebola is difficult because the early symptoms, such as red eyes and rashes, are common.

Ebola infections can only be diagnosed definitively in the laboratory by five different tests.

Such tests are an extreme biohazard risk and should be conducted under maximum biological containment conditions. A number of human-to-human transmissions have occurred due to a lack of protective clothing. 

“Health workers are particularly susceptible to catching it so, along with treating patients, one of our main priorities is training health staff to reduce the risk of them catching the disease whilst caring for patients,” said Henry Gray, MSF’s emergency coordinator, during an Ebola outbreak in Uganda in 2012. Henry also worked on the 2014 outbreak. 

“We have to put in place extremely rigorous safety procedures to ensure that no health workers are exposed to the virus – through contaminated material from patients or medical waste infected with Ebola.”

Treating Ebola

There are currently two trial vaccines for Ebola, one of which is already in use in DRC.

The Merck vaccine is estimated to offer effective protection for 97.5 percent of participants 10 days after vaccination and is a promising tool in the fight to contain the outbreak.

Due to the limited availability and investigational status of the vaccine, the vaccination strategy is limited to a ring approach and only direct and indirect contacts of confirmed or probable Ebola cases and frontline workers who are eligible to be vaccinated.

However, successful contact tracing has proved notoriously difficult in DRC and MSF supports recommendations to expand vaccination activities to cover the entire population that is at risk.

Such steps are needed urgently if we are to prevent the epidemic from lasting another year.

At the same time, a second experimental vaccine produced by Johnson & Johnson has been given the green light in DRC as part of an extended clinical trial and MSF is part of the global consortium leading the rollout.

As of 17 November 2019, the start date of vaccination activities was yet to be confirmed.

Once a patient recovers from Ebola, they are immune to the strain of the virus they contracted.

An Ebola outbreak is officially considered at an end once 42 days have elapsed without any new confirmed cases.

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