DR Congo Ebola Outbreak Response

We will fight DR Congo current Ebola Outbreak just like we did in West Africa.....

Responding to an Ebola outbreak has never been easy, but the new epidemic in DR Congo poses daunting challenges. The first of these challenges is the virus itself – there are six known strains of Ebola virus, including the newly discovered Bombali strain in Sierra Leone. All of them are part of the Filoviridae family which also includes Marburg virus. The strain causing the current outbreak in Beni, the Zaire strain, is the most lethal of all of them, fatal in up to 90% of cases. The deadly virus could not have found a more hazardous time and place to flourish; a nearly inaccessible region at the epicenter of one of the most violent theaters of conflict in DR Congo, where the crossfire is a constant threat to humanitarian response efforts.

When I informed my colleagues and family that I was going to another epicenter of the outbreak in Beni, Democratic Republic of Congo, I could see the apprehension on their faces. Fortunately, they know from my experience in West Africa that I was well prepared. The objective of International Medical Corps is to bring the number of Ebola cases in DR Congo to Zero. You need to be mentally and physically prepared to step up to a mission like that. My experience implementing training, techniques and protocols to deal with Ebola are what give me the confidence to go into this situation yet again.

Calm Before the Storm… When I joined International Medical Corps as Medical Coordinator earlier this year, I didn’t know I would be responding again to Ebola. I signed on to be deployed in Bunia, in the Ituri Region of DR Congo. We were responsible for providing primary and secondary health care to more than 45,000 internally displaced persons (IDP’s) who had settled just outside Bunia General Hospital after running away from fighting that erupted in Djugu Region in mid-December 2017. Our two main objectives were to provide health care through clinics and referrals at the health centers, and to provide improved water and sanitation for health (WASH) access and capacity building to raise awareness and prevent outbreaks of infectious diseases like cholera and Ebola. We partnered with the Ministry of Public Health (MoPH) and international and local NGOs - including Caritas, SANRU and SOFEPADI - to address issues like malnutrition and gender-based violence.

The first step of my journey to DR Congo was a flight from Nairobi, Kenya, to Kigali, Rwanda in July, 2018. At that time DR Congo had just started containing an Ebola outbreak. I remember talking to the airline crew, asking her what precautions they take to set up prevention barriers for passengers potentially carrying the virus. I pictured travelers arriving by road from DR Congo to Kigali, boarding the 1-hour flight to Nairobi and departing onward to virtually anywhere in the world, with the risk of carrying the epidemic with them. She seemed unsure how or what to answer but smiled at me “normal PR stunt in airline staff.” When I arrived in Kigali, I gave her one of my small disinfectant bottles I carry in my backpack, handed her a small educational poster on Ebola prevention, and told her to be careful and take precautions, I told her that Ebola is a different ball game.

From there I took a taxi from Kigali to the Gisenyi border. It was a pleasant four-hour drive overlooking a good view of Rwanda, which lived up to its reputation as the “Land of a thousand hills” or "Pays des Mille Collines" in French. Reaching Goma in Nord Kivu, everything seemed to be business as usual. The most recent Ebola outbreak in DR Congo had not been declared over and had occurred thousands of kilometers away in Bikoro, a small lakefront community in a rural area of Equateur province. North Kivu has never had a case of Ebola before.

Taking a Step Back: The 9th Ebola Outbreak

Democratic Republic of Congo is no stranger to Ebola outbreaks. Earlier in the year, on May 8th, the government of DR Congo declared an outbreak of the virus in Bikoro in Equateur Province on the western border. Laboratory results confirmed two cases. It was the 9th Ebola outbreak which the country had faced since the 1970s. None of those outbreaks were connected to the massive one in Guinea, Liberia and Sierra Leone that began in 2014 and left more than 11,300 dead.

By mid-May, numbers were up and concern was mounting; cases of Ebola had been confirmed in Mbandaka, a sprawling city of more than a million people close to the Congo River. The region seemed to be hovering on the brink of crisis.

Nevertheless, by the end of June, the DR Congo Ministry of Health (MoPH) reported that all of the people they knew had been exposed to the virus had gone 21 days without showing any sign of infection. On July 24, after two full incubation periods had passed with no sign of another case, WHO and MoPH declared the end of the 9th Ebola outbreak. It had resulted in 54 confirmed cases, including 33 deaths. Health officials credited a quick international response from NGOs like International Medical Corps and fielding of vaccinations against Ebola to more than 3,300 people as major factors in containing the outbreak.

Just a week later, on the opposite side of the country, preliminary lab results revealed a new outbreak of hemorrhagic fever. The 10th Ebola outbreak in DR Congo had begun.

The 10th Ebola Outbreak

The DR Congo Minister of Health notified the World Health Organization on 1 August 2018 of a new Ebola outbreak in the Mabalako health district in North Kivu province. The ground zero of the epidemic was Mangina, bordering the Ituri region where tens of thousands of IDPs remained in the Bunia camp. The area is home to half a dozen trading hubs: Goma, Butembo, Beni, Mangina, Mambasa, Oicha and Bunia. Goods and services travel between these cities and back and forth into nearby Uganda, Sudan and Rwanda. If the Ebola outbreak began to spread, dozens of communities lay directly in its path of destruction. Every health care worker was on high alert.

I was already in Bunia when the announcement declaring the 10th Ebola outbreak came through local radios and the United Nations FM Station famously known as “Radio Okapi.”

At that time, I had a team of two national doctors, four nurses and 14 community health care workers managing the threehealth centers for IDPs. There were 12,000 IDPs in the camp and another 8,000 leaving within the host community in Bunia. Having garnered enough experience working with International Medical Corps during the West Africa outbreak, my mentality switched. I was in alert mode.

Protecting our team was my priority. I knew from my previous experience that confusion was our first enemy. Everyone had misconceptions and views about Ebola, including the local staff. For some it is a curse from God, forothers it is brought on by witchcraft. Some are torn between different theories and scenarios. I needed to act as quickly as possible to create awareness among our team and help them to  understand the facts and reality on the ground. They needed to know how the disease is spread and how it can be prevented. Having the whole team on the same page and moving in the same direction is crucial.

I put my team together and organized Ebola prevention training for all staff. We divided ourselves into groups for interventions (Medical, WASH and Surveillance). We set up standard operating procedures (SOPs) and started implementing them in our office and guest house first, then moved to our three health centers and set up hand washing stations at every entrance. Every person coming to visit the health centers had to adjust to the changes too. They had to wash their hands and have their temperature checked before entering. We created an invisible barrier (distance) between patients and our medical team when attending to the patient. As a medic with experience treating Ebola patients, I understood clearly what to do and what not to do in this situation. Ebola virus isn't airborne, but it moves from one person to another through contact with infected bodily fluids. I knew I had to limit contact with people including my teammates and set up a “No hand shaking or hugging policy.” I also knew that only an active case would be contagious.

As the saying goes, train one CHW and you’ve trained a whole community. Our 14 CHWs went from block to block within the IDP camp and host community to do outreach and awareness on Dangers of Ebola. They explained to the people there how the disease is transmitted and taught preventive measures that the community can implement to protect themselves.

Meanwhile, the Government run health centers including the General Hospital in Bunia were moving slowly to take precautions as the famous Lingala saying goes, “Malembe – Malembe” or slowly slowly.

 We held meetings with the Ituri Region health team and advised on the precautions they needed to take to protect themselves. 90% of the health care workers in the Ituri region had no Ebola training. The region had never seen an Ebola case before. The Zonal Health Team agreed that International Medical Corps needed to conduct training to prepare the health sector for the epidemic. The DR Congo MoPH selected 45 health care workers who underwent a three day course called Infection, Prevention and Control, or IPC. We also established hand washing stations in all entrances of the main General Hospital.

 200 kilometers away in Beni, the number of cases were increasing. IMC was already on the ground constructing an Ebola Treatment Center (ETC) for patients and several Screening and Referral Units (SRU) to detect potential cases. They had also taken the first initiative to conduct IPC training to 30 health care workers each week. I left Bunia and deployed to Beni to train and set up a response team.

When I arrived at the airport in Bunia to board my UN Humanitarian Air Service (UNHAS) flight to Beni, they already set up units for hand washing, including all entrance and exits at the airport. Several ground check points were established for screening, which included hand washing and temperature checks. Everyone takes handwashing very seriously. No one – not even senior government officials – can get in or out without washing their hands.

In Beni I had with me a team of local nurses and doctors. The vast majority of our incoming staff had no previous experience with Ebola. We needed to take them through MATCO (Multi-Agency Training Collaborative) Ebola and IPC training. Everything was new to them and we had to take it step by step, especially when it came to donning and doffing their personal protective equipment or PPE. The MATCO – Ebola training which was developed and very effectively utilized during the West Africa outbreak seemed to be working again in DR Congo. In less than three weeks our entire team was ready to start working at the ETC. Those on the frontline were also given the new experimental vaccine against Ebola.

 Commuting to Work: A Day Drive to the ETC in Makeke

From our base in Beni to the ETC in Makeke, it is a 90-minute drive over unforgiving bumpy roads. Along the way we came across three checkpoints set up by the International Organization for Migration (IOM) screening travelers. All vehicle occupants including the driver would come out of the vehicle, wash their hands, and do temperature check before climbing back into the vehicle and continuing with the journey.

 Arriving at Makeke, I could see that the local health workers already had demarcated the area for active cases to limit contact and avoid infecting others. It was reassuring to see that the local teams on the ground knew what they needed to do.

 The response team has good job of identifying the cases (people who have been exposed to Ebola), their contacts and the contacts of contacts very early on. This is good news, because it means a quarantine will probably not be necessary.

 Still, it is a stressful situation. When I met the people in the affected communities who needed our support, that immediately brought my mind into focus. No time for my own anxieties. Any fears I had disappeared when I met our colleagues and local partners on the ground; their professionalism gave me an immediate relief. It’s reassuring to be a part of a global team of experts who really know what they are doing.

The impact of our team effort is visible. We understand from past experience in West Africa and in the DR Congo that handwashing, good hygiene, and sanitation are critical to reducing the risk of disease transmission. During my visit to the affected area, I heard a community leader talk about sanitation, handwashing and water. The message is getting through. The government, too, has learned from experience and it shows. The fact that they declared the outbreak early makes me feel confident about the ongoing response.

 It’s been a little over several weeks since the outbreak declaration, and we can see the effective response that is underway. If we are able to do our case findings early and then treat the patients we discover, we will be able to contain this outbreak. We have clear, established protocols. To protect our staff and be prepared for the unexpected, we make sure that staff who go to an active zone have an individual protective kit, no matter how far or close they are to the outbreak area.

Nord Kivu: The Violent theater of conflict in DR Congo

 The rebel violence ignites social tensions in the community that then affects our efforts. When people feel unsafe because of rebel attacks, they stop caring about our health message

Home to around or more than 8 million people, North Kivu is one of the most densely populated provinces of the Democratic Republic of the Congo. It shares borders with four other provinces (Ituri, South Kivu, Maniema and Tshopo) and with the countries of Uganda and Rwanda.

 The far north of the province offers a semblance of peace, but the situation in this part of North Kivu Province is very unstable. It is an area dominated by armed conflict. The implications for humanitarian response are severe, with a risk of deliberate attacks and acts of hostility against facilities, personnel and property during periods of tension. The response teams must show considerable patience.

The history of violence in North Kivu province stretches across decades. The province and its neighbors bear the scars of brutal machete attacks, massacres, kidnapping and mass rapes perpetrated by combatants on all sides of the conflict. UNHCR reports that one million people in North Kivu are displaced by the conflict. According to the Congo Research Group at New York University, there are 134 active armed groups in the North and South Kivu provinces, responsible for 49 violent deaths, 103 kidnappings and 32 clashes in August alone. The violence threatens health care workers and facilities directly, blocks their movement and activity, renders Ebola patients and their potential contacts inaccessible, and allows the epidemic to follow the unpredictable movement of displaced people as they flee. Surges in violence are followed by upticks in the number of cases as those affected become unreachable to the health care teams and receive care from untrained family members instead.

 On 22nd October 2018 we drove back from Makeke to Beni only to be welcomed by heavy Gunfire within Beni when fighting erupted between the Rebels and Government Military personnel, all of us were put on lock down at our guest house with no movement, level of security was raised to level 4 meaning “Have your go bag ready and wait for movement or evacuation message”

 We depend a lot on MONUSCO for security updates and evacuation movement, as a Non-Governmental organization we believe in Community protection than police or military.

 The fighting lasted whole night, and the next day there was a lot of anger from the community within Beni leading to riots and stoning of vehicles especially those with UN and NGO logo.

 It brought my memory back when I was working in Guinea Conakry and community used to stone vehicle with NGO logo that we had to operate for several months without organizations LOGO in our vehicles not even wearing organization Tshirts, at some point it helps. the main violent area is between Beni, Mbau and Kamango which is also referred to as “TRIANGLE OF DEATH” by the “blue helmet" – UN Peace keepers.

 After Sept. 22, 2018 attack by the ADF that killed around 17 civilians in Beni, the city of 200,000 people declared a “ville morte” ― a week of public mourning and demonstrations that disrupted Ebola response activities.

Sept. 24 until Sept. 26, 2018 we were unable to trace Ebola patients’ contacts and do other important containment work. Contacts reached by Ebola teams plummeted from the 90 percent range to 20 percent in the day after the attack. As the days went on without access to contacts, the disease spread. People also cared for the sick in their homes without medical supervision, which is part of the reason for the large uptick in cases.

Is there a cure?

There's no known cure for Ebola, which means doctors and nurses are left to do what they can to provide supportive care like fluids and treat symptoms.

 On June 4, however, an ethics committee in Congo gave its approval for the use of five investigational treatments for Ebola under a compassionate use framework

"This is the first time such treatments are available in the midst of an Ebola outbreak," WHO said in a statement. Clinicians on the ground will make decisions on which drugs to use. 

"The treatments can be used as long as informed consent is obtained from patients and protocols are followed, with close monitoring and reporting of any adverse events."

In addition, the experimental vaccine fielded in the 9th Ebola outbreak and credited with contributing to the success of the response is also now being tested in the latest outbreak.

 After MATCO Ebola training, we took all our staff for Prototype Drug training conducted by WHO, the training Consultation on Monitored Emergency Use of Unregistered and Investigational Interventions for Ebola Virus Disease (EVD) also known as MEURI protocol

The drugs are:

●     ZMapp (a monoclonal antibody cocktail)

●     Remdesivir (GS-5734) (an antiviral drug)

●     REGN3470-3471-3479 (a monoclonal antibody cocktail

●     Favipiravir (an antiviral drug)

●     Review of mAb 114 (a monoclonal antibody)

 MEURI - Consultation on Monitored Emergency Use of Unregistered and Investigational Interventions for Ebola Virus Disease (EVD)

 There are many pathogens for which no proven effective intervention exists. For some pathogens there may be interventions that have shown promising safety and efficacy in the laboratory and in relevant animal models but that have not yet been evaluated for safety and efficacy in humans. Under normal circumstances, such interventions undergo testing in clinical trials that are capable of generating reliable evidence about safety and efficacy. However, in the context of an outbreak characterized by high mortality, it can be ethically appropriate to offer individual patients’ investigational interventions on an emergency basis outside clinical trials. The WHO developed an ethical framework known as Monitored Emergency Use of Unregistered Interventions (MEURI1.) which established the following criteria to be met for access to investigational therapeutics for individual patients outside of clinical trials:

●     No proven effective treatment exists;

It is not possible to initiate clinical studies immediately;

●     Data providing preliminary support of the intervention’s efficacy and safety are available, at least from laboratory or animal studies, and use of the intervention outside clinical trials has been suggested by an appropriately qualified scientific advisory committee on the basis of a favorable risk–benefit analysis;

●     The relevant country authorities, as well as an appropriately qualified ethics committee, have approved such use;

●     Adequate resources are available to ensure that risks can be minimized; 6) the patient’s informed consent is obtained; and

●     The emergency use of the intervention is monitored, and the results are documented and shared in a timely manner with the wider medical and scientific community.

 Strategies from WHO on fighting Ebola in Beni

●     Strengthening coordination of the multisectoral response through epidemic control committees at different levels.

●     Strengthening surveillance, active case-finding and con-tact monitoring

●     Establishment of controls and targeted health measures at PoE

●     Strengthening diagnostic capacity at laboratories

●     Medical treatment of patients and suspected cases

●     Strengthen biosafety precautions at health facilities

●     Strengthening of community protection measures

●     Risk communication, social mobilization and community involvement

●     Psychosocial care

●     Vaccination of at-risk groups

●     Free access to health services

●     Operational and logistics support

●     Security precautions Guarantee the security of human and material resources involved in the response effort.

 At the end of the day is going to be tough, is going to be high risk, is going to be insecure, things will change within seconds, one second your treating an Ebola patient and few minutes later you’re in secure zone with your go bag, is a big test to both humanitarians and patients, do you give up? NO, you toughen up, encourage each other, work as a team, stay alert and mostly achieve your goal in bringing Ebola to Zero in Nord Kivu, all parties involved including government and community at large work together and share information on progress in each stage. We live and work together as one big family with one Mission and Objective….Ebola where will you run?

  Always hope for the best but prepare for the worst, what doesn’t kill you only makes you stronger

My Name is Elvis Ogweno MPH/MSc/EMT-P a Public Health Specialist and Tactical Paramedic with vast experience in emergency response to epidemics and complex humanitarian disasters. He is currently working as the Medical Coordinator for the International Medical Corps (IMC) Ebola Treatment Center in Beni, Democratic Republic of Congo.

We are here to stay, fight the Virus hard and bring it to Zero. God Bless you ALL