The outbreak is still not under control
19 July 2019
Democratic Republic of Congo (DRC) declared their tenth outbreak of Ebola in 40 years on 1 August 2018. The outbreak is centred in the northeast of the country. With the number of cases passing 2,500, it is now by far the country's largest-ever Ebola outbreak. It is also the second-biggest Ebola epidemic ever recorded, behind the West Africa outbreak of 2014-2016.
During the first eight months of the epidemic, until March 2019, more than 1,000 cases of Ebola were reported in the affected region. However, between April and June 2019, this number has doubled, with a further 1,000 new cases reported in just these three months. Since early June, the number of new cases notified per week has remained high, averaging between 75 and 100 each week.
As of early July, there are 25 affected health zones out of a total 47 in the provinces of North Kivu and Ituri, 22 of which are considered as active transmission zones – meaning that they have notified new confirmed cases in the last 21 days. Two new health zones, Ariwara and Goma, were recently added to the list. While the number of new cases is decreasing in former hotspots such as Butembo, Katwa & Mandima health zones, there has been an increase in new cases in Beni and a steadily high incidence of cases in Mabalako health zone.
Violent attacks against those working in the Ebola response continue to hamper efforts to bring the epidemic under control. On 25 May, a health worker was killed in Vusahiro while working to prevent the spread of Ebola. On 25 June, angry crowds hurled rocks at a driver working with an Ebola response team in Beni and set his vehicle on fire. On 13 July, two Ebola health care workers were killed by unidentified assailants, in Beni, North Kivu province. There is no clear information about the motives of this incident.
Not only does this targeted violence disrupt crucial activities like vaccination, contact tracing, community health promotion and safe burials, but it also discourages people from coming to the Ebola Treatment Centres when they fall ill and present Ebola-like symptoms.
Contributing to this is the difficulty in identifying and following up contacts of people diagnosed with Ebola. Since the beginning of the epidemic, only around half of the new reported Ebola cases have been identified as contacts of previously confirmed cases before falling ill and seeking treatment, or dying without receiving proper treatment for Ebola.
On 11 June 2019, Uganda announced that three people had been positively diagnosed with Ebola, the first cross-border cases since the outbreak began.
On 14 July, the first case of Ebola was confirmed in Goma, the capital of North Kivu, and a city of one million people. The patient, who had travelled from Butembo to Goma, was admitted to the MSF-supported Ebola Treatment Centre in Goma. After confirmation of lab results, the Ministry of Health decided to transfer the patient to Butembo on 15 July, where the patient died the following day.
In reaction to the first case found in Goma, on 17 July 2019, the World Health Organization (WHO) announced that the current Ebola outbreak in DR Congo represents a public health emergency of international concern (PHEIC).
Given the ongoing challenges in responding to the outbreak, MSF believes that Ebola-related activities should be integrated into the existing healthcare system, in order to improve the proximity of the services to the community and ensure that it remains functional during the outbreak.
Background of the epidemic
Retrospective investigations point to a possible start of the outbreak back in May 2018 – 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 the one affecting the current outbreak.
First declared in Mangina, a small town of 40,000 people, the epicentre of the outbreak appeared to progressively move towards the south, first to the larger city of Beni, with approximately 400,000 people and the administrative centre of the region. As population movements are very common, the epidemic continued south to the bigger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018 and cases had been found further south, in the Kanya area. Meanwhile, sporadic cases also appeared in the neighbouring Ituri province to the north.
Overall, the geographic spread of the epidemic appears to be unpredictable, with scattered small clusters potentially occurring anywhere in the region. This pattern, along with the lack of visibility on the epidemiological situation, is both extremely worrying and makes ending the outbreak even more challenging.
Located in northeastern DRC, North Kivu province is a densely-populated area with approximately 7 million people, of whom more than 1 million are in Goma, the capital, and about 800,000 in Butembo. Despite the rough topography and the bad roads in the region, the population is very mobile.
North Kivu shares a border with Uganda to the east (Beni and Butembo are approximately 100 kilometres from the border). This area sees a lot of trade, but also trafficking, 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 province is also well-known for being an area of conflict for over 25 years, with more than 100 armed groups estimated to be active. Criminal activity, such as kidnappings, are relatively common and skirmishes between armed groups occur regularly across the whole area.
Widespread violence has caused population displacement and made some areas in the region quite difficult to access. While most of the urban areas are relatively less exposed to the conflict, attacks and explosions have nonetheless taken place in Beni, an administrative centre of the region, sometimes imposing limitations on our ability to run our operations.
MSF’s main priority is to work closely with communities to identify their needs and ensure that access to essential healthcare services is guaranteed for patients suffering from all major diseases affecting the population in the area, including Ebola. In order to achieve this, we are working within local health structures. MSF also aims to integrate its Ebola response activities into the existing healthcare system to ensure the proximity of such services to those who need them.
We recently restarted provision of care for confirmed Ebola patients in areas of active transmission- that is Bunia-Ituri province – in collaboration with the Ministry of Health. Additionally, MSF is finalising the construction of an Ebola treatment Centre in Goma. However, most of our activities are focused on supporting existing health structures that provide essential healthcare services to the population, in addition to care for patients suspected of being infected with Ebola, strengthening triage and infection prevention and control activities (IPC), building transit units within general health facilities and implementing community engagement activities. We are also strengthening the surveillance system in the programmes we run outside the areas directly affected by the outbreak.
As of July 2019, MSF has more than 530 staff deployed in DRC for the Ebola emergency and supports the ministry of Health by providing incentives to 745 of its staff.
MSF is currently running the following activities in the provinces of North-Kivu and Ituri affected by Ebola: (a total of 9 projects)