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As Ebola outbreak ends in Congo, new cluster emerges
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On July 24, WHO announced that the Ebola outbreak in the Democratic Republic of the Congo, or DRC, was over following 3 months of quick action — including giving almost 3,500 people an experimental vaccine. However, another outbreak was announced a week later. As of press time, it was unclear whether the two outbreaks were related.
The previous outbreak — the ninth in the country’s history — was centered in the hard-to-reach town of Bikoro but spread to other areas, including Iboko and the large city of Mbandaka, roughly 80 miles away. Officials responded to the outbreak within 24 hours of it being declared, eventually setting up dozens of screening points along the Congo River, which acts as a highway for the remote area.
Tarik Jasarevic, WHO spokesman, said that the agency learned many painful lessons from the devastating West African Ebola epidemic of 2014, including that the world expected much more from WHO than it was able to deliver.
“When this outbreak struck, we were ready,” Jasarevic told Infectious Disease News.
Within hours of the first cases being confirmed, WHO had allocated more than $2 million from its Contingency Fund for Emergencies and deployed a team to the field, Jasarevic explained. Before long, WHO had 250 people on the ground, including epidemiologists, logisticians, clinicians and data managers, working with government teams.
“We made better use of the tools we have for fighting Ebola — strong surveillance to make sure we knew where the virus was spreading, community engagement to ensure safe burials and awareness of symptoms, and compassionate care to treat the sick and prevent further transmission,” Jasarevic said.
Three lessons
During the outbreak, which began in April, 54 people contracted Ebola virus and 33 people died, according to WHO.
Oly Ilunga Kalenga, MD, the DRC’s minister of health, said in a statement that no new cases had been confirmed since June 6 and that the last confirmed case was treated and cured at the Bikoro Ebola treatment center on June 12. After a 42-day observation period — twice the length of the virus’ incubation period — he declared the outbreak over.
“This result would not have been possible without the dedication and professionalism of the Congolese health care providers, who gave the best of themselves to serve the nation and make life triumph,” Kalenga said in a statement. “I want to express my gratitude to them.”
Kalenga added that this outbreak presented more significant risks than previous outbreaks. It started in two health zones at the same time; health workers were among the first victims, which increases the risk of further transmission; and the outbreak reached the city of Mbandaka, which has more than 1.2 million inhabitants along the Congo River.
Although these challenges posed a large threat, DRC officials and health agencies acted swiftly and were able to contain the outbreak in a relatively short time.
Kalenga says there were three lessons officials and government responders learned — lessons he feels should be heeded by any country facing such an outbreak.
“Nothing can replace the leadership of the government,” Kalenga told Infectious Disease News. “The Ministry of Health is responsible for the health and well-being of the Congolese population. We had to take the lead in order to fulfill our commitments toward the population.”
These commitments cannot be handled alone, which is the second lesson Kalenga learned.
“Avoid chaos on the field by carefully selecting your partners and by aligning them with the government’s plan and priorities,” he said.
The third lesson, he said, is to get the community involved.
“We worked with traditional and religious leaders but, in times of crisis, support can also come from unusual quarters,” Kalenga said. “That was the case in Mbandaka, where 4,000 motorcycle taxi drivers became our strongest health advocates.”
These motorcycle drivers were among those who were vaccinated so that they could transport confirmed Ebola patients to health centers for treatment, he explained.
Quick reaction
Anne W. Rimoin, PhD, MPH, associate professor of epidemiology the University of California, Los Angeles School of Public Health, runs a research program in collaboration with the DRC Ministry of Health that has focused on emerging infectious diseases and strengthening disease surveillance for 16 years.
Rimoin says that the quick, coordinated response to the outbreak was crucial.
“As soon as the outbreak was declared, the DRC Ministry of Health and partners swiftly moved to contain the outbreak,” Rimoin told Infectious Disease News. “The Congolese Ministry of Health and partners had a coordinated response that was very effective.”
The introduction of a vaccine also likely had an impact, she added.
“The vaccine is experimental, and we still need to understand more about how well it works and how long the protection it provides lasts, but it is an important new tool that will likely play a key role in future outbreaks.”
The vaccine, Merck’s V920, was available during a 2017 outbreak, but officials elected not to use it after learning that the outbreak did not spread beyond known contacts of the infected. The vaccine has not been approved in any country to date, but Merck has stockpiled more than 300,000 doses and donated nearly 7,500 of them to the DRC to battle the outbreak.
Treatment facilities in each of DRC’s affected areas were stocked with the vaccine and began treatment on a voluntary basis. The campaign began on May 21 in Mbandaka, with the first doses given to front-line health care workers and then to anyone who had contact with confirmed Ebola cases or contacts of those people, a strategy called ring vaccination.
Officials from Doctors Without Borders assisted with the 3-month emergency intervention and administered vaccinations.
Micaela Serafini, medical director for Doctors Without Borders, said in a statement that the group is heartened by advances made in the recent outbreak response.
“The data are still being analyzed, but we are encouraged that this vaccination, as well as the rapid international response and concerted outreach efforts into the remote communities, contributed to stemming the spread of this deadly virus,” he said.
“We also hope that the resources dedicated to this Ebola intervention will have a long-term positive impact in the future by strengthening the capacity of DRC’s health system,” Serafini added.
Building on momentum
The Ebola virus can sometimes persist in survivors and be transmitted through bodily fluids like semen and breast milk. Ebola virus RNA has also been discovered in the cerebrospinal fluid and aqueous humor of survivors, according to a study published in The Lancet Infectious Diseases. These transmissions can lead to flare-ups and the re-emergence of Ebola cases for undetermined periods of time following an outbreak.
However, vaccination may decrease the risk for flare-ups, officials said.
“We are now beginning to understand that on rare occasions, the Ebola virus may persist in a person long after recovery from acute infection,” Rimoin said. “This does not appear to be a common event, but since it is possible, it’s great that there is now a vaccine available that may be able to provide protection to close contacts of Ebola survivors.”
Kalenga said flare-ups from this latest outbreak are “not a concern.”
“Our epidemiologist did a great job identifying contacts and transmission chains,” he explained. “With the ring vaccination, we managed to quickly break these transmission chains and contain this outbreak.”
Although this outbreak ended “successfully,” according to Kalenga, with its quick containment and a vaccine that could have lasting effects on the region, officials said they could not have anticipated an epidemic arising on Aug. 1, roughly 1 week after the declaration of the ninth outbreak’s end. The announcement came after the Provincial Health Division of North Kivu notified the Ministry of Health of 26 cases of fever with hemorrhagic signs, with 20 deaths. Six samples were sent to the Institut National de Recherche Biomédicale in Kinshasa, where four tested positive for Ebola virus.
“Although we did not expect to face a tenth epidemic so early, the detection of the virus is an indicator of the proper functioning of the surveillance system put in place by the General Directorate for Disease Control,” Kalenga said.
WHO says it got a head start on the latest epidemic with numerous resources, including staff and equipment, already on the ground from the last outbreak. Officials said they were unsure if the cluster of Ebola cases, mostly centered in the Mangina health zone, is related to the ninth outbreak.
Kalenga says the Ministry of Health is closely monitoring survivors of the outbreak that was recently declared over, and that researchers are working to collect more data to anticipate the needs of survivors and to prepare for future outbreaks.
WHO is calling for the DRC and the international community to build from the positive momentum gained by the outbreak’s quick containment.
“This effective response to Ebola should make the government and partners confident that other major outbreaks affecting the country, such as cholera and polio, can also be tackled,” WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, said in a statement. “We must continue to work together, investing in strengthened preparedness and access to health care for the most vulnerable.” – by Caitlyn Stulpin
- Reference:
- Dokubo EK, et al. Lancet Infect Dis. 2018;doi:10.1016/S1473-3099(18)30417-1.
Disclosures: Jasarevic, Kalenga, Rimoin, Serafini and Tedros report no relevant financial disclosures.