DR Congo Ebola Virus Outbreak Surpasses 1000 Deaths........How did we get here?

Ebola Virus Disease Outbreak and Response Overview

This past Friday May 10, 2019, the Ministry of Health, Democratic Republic of Congo (DRC) reported that there have been 1,662 cases of Ebola virus disease (EVD) with 1,574 confirmed and 88 probabale during the eight-month outbreak occurring in the restive eastern provinces of North Kivu and Ituri. The outbreak has now exceeded 1,000 deaths as of Friday. Unlike the outbreak in West Africa, the latest epidemic can be contained in theory. Despite the vaccination of over 94,000 people, not including 29,000 health care workers and first responders with Merck & Company’s experimental rVSV-ZEBOV-GP ebola vaccine which has been found to be 97.5% effective in preventing the disease, there were still an additional 13 newly confirmed cases and another 325 cases suspected. North-Kivu and Ituri’s past and current state of civil conflict has made it difficult to trace cases and implement a proven vaccination strategy called “ring vaccination” which works by tracing and vaccinating all known suspected contacts of people infected with Ebola virus, along with the healthcare workers. In addition to political instability and hostile conflict situations, the ability to secure sufficient financial resources to manage both the outbreak and conflict has proven to be an additional hurdle while local politicians with alternative agendas to manipulate elections contribute to the spread of fear-provoking misinformation which further slows response, containment, and vaccination efforts.

As the world’s second-deadliest Ebola outbreak in history continues to ravage communities in the DRC, international aid groups are reconsidering response efforts after a string of attacks in recent weeks by armed assailants on health centers which resulted in injuries and fatalities to healthcare workers. To date, five Ebola treatment centers and several health care facilities have been attacked in rapid succession which included the death of visiting expert epidemiologist from Cameroon, Dr Richard Valery Mouzko Kiboung in Betembo, a city in North Kivu. The attacks have severely impacted coordinated efforts of case detection, treatment, and vaccination in these conflict zones and called for a need in increased security resources for medical personnel, community health workers and first-responders. Resulting gaps in surveillance and response will have a significant impact on the number of future cases and add to the difficulty containing the outbreak and preventing the spread of EVD to neighbouring countries such as Uganda and South Sudan through the porous borders and waterways that allow for surreptitious migrations between countries, particularly during times of conflict.

Current Issues

Reports originating from the DR Congo indicate that besides having to deal with armed conflict, the region’s population also expresses a high level of mistrust that is reportedly growing rapidly among local communities. This mistrust not only targets outsiders, but also extends to anyone affiliated with the government, including locals who may be assisting in vaccination and containment efforts. Some people in this region still do not believe that the Ebola virus is real and think the outbreak is confabulated by the government of DRC and the MoH and its partners as part of a political ploy, while others do not believe in the safety of the vaccine in general. Some people have avoided vaccination because they believe the vaccine is a poison or something to make them sick. Unfortunately, the arrival of aid or a vaccine usually coincides with an outbreak, making it much easier to make a false association between the two events perpetuating any existing mistrust.

Furthermore, recent rapid survey studies published in the Lancet indicate that a large number of people do not read the language or comprehend the signage that has been provided to inform communities about what Ebola virus is and how it spreads, or how to contain it. This includes educational material and consent forms for vaccination because they were produced without local consultation and distributed mostly in French and is not sufficiently inclusive or all the dialects in the region. For example, one survey noted that a particular sign showing people displaying symptoms of EVD and a building was incorrectly interpreted as meaning that suspected Ebola cases are not welcome at hospitals or treatment centers. As a result people either did not seek help in a timely manner or did not seek help at all. This spread of misinformation in addition to language barriers and conflict has allowed for the virus to continue its spread in this region.

The surge of cases in previous weeks is believed to be attributed to an unsafe burial on the 25 July, 2019 of a woman deceased from EVD in the North Kivu town of Mangina. Unsafe burials of the deceased are deeply rooted in cultural traditions and involve extensive touching and washing of the body. This activity is something that must not be undertaken during an EVD outbreak, especially with someone who was infected with the Ebola virus. Acceptance of this behavioral change is difficult for many people and some choose to perform burials of deceased relatives in secret in order to honor customs and beliefs of their culture.

Need to Involve Local Power

At this point it is critical to take the time to reflect and ask the following questions:

1.    How did we get here today?

2.    Where did we go wrong?

3.    How do we create change to breakdown the wall of mistrust built by previous ill-conceived attempts to help these communities so that we can be better prepared for future outbreaks?

4.    How are we going to sustain these changes?

 Since researchers believe the natural reservoir for the Ebola virus is most likely a species of fruit bat, the virus is therefore endemic to the region, and thus unable to be eradicated. In addition, unsafe burial customs and population displacement into the surrounding rain forest puts people at greater risk of coming in contact with the Ebola virus through exposure to infected bat guano or consumption of infected bush meat. Only change in human behaviors can reduce the number and severity of outbreaks. These behavioral changes will depend heavily on who sends the messages for change, the language of the messages, and their ability to be comprehended, adopted, and sustained by the community. Examples of positive behavioral changes that could be elicited from proper community inclusion and education include less vaccine hesitancy, decreased likelihood to seek help when ill, and more compliance with safe burial practices.

There are growing calls locals to listen to community health workers when responding to the Ebola virus outbreak. In order to build trust it is necessary to have more community engagement from the beginning at all levels during an outbreak. The concept of employing community engagement is surprisingly not new and was first recognized by the psychologist Kurt Lewin in the early 1900’s but was not really used or understood as a pragmatic tool for community engagement and to gain trust until recently. In reality, it should be the affected communities and their members who are running the Ebola response effort because they have answers, not the foreigners who come, give the locals brief paternalistic lessons in order to indoctrinate them about what they should do without cultural sensitivity. Grassroots movements are becoming more important than ever in combatting EBV outbreaks in rural regions such as North Kivu and Ituri Provinces.

This past effort was very much a top-down approach which was not well received by a community in turmoil. In order to build trust, you need to first engage with the community and this can be done through the creation of community focus groups that include tribal or religious leaders and other important representatives that are respected by the community in order to help build a rapid assessment of local needs. This trust is needed for local capacity building and is critical to ensure future sustainability after outbreak response activities cease. One great lesson learned is that the quickest response can come from a prepared and well-informed community. Further work needs to be done in order to rebuild the communication bridge that was so poorly constructed at the start of this outbreak.

Sustainability also calls for basic healthcare infrastructure to be in place to address other diseases like malaria, which create a severe disease burden in the area. With a basic healthcare infrastructure in place and the addition of an operational surveillance system we can avoid large outbreaks like this in the future while also having trained community health workers treat diseases like malaria, for example. The intended plans for sustainability should be integrated into the latest Strategic Response Plan for Ebola.

After reports were heard that some people in North-Kivu and Ituri cannot understand why they are only being helped now solidifies the importance of those who are responding or contributing resources to the current response to come together in order to devise a common strategy of how much longer they will stay after the outbreak and how much they intend to contribute so that we can calculate the resources needed to strengthen the health care system and mentor health care workers in response to future outbreaks while still on-site. Protracted fighting in eastern Congo has deepened the vacuum for health services in a region where malaria, cholera, and other diseases have killed far more people than Ebola, therefore we should use this window of opportunity that has arisen from the current Ebola outbreak as a springboard to implement better sanitation and an overall stronger and more proactive healthcare system, particularly in the rural Provinces of North Kivu and Ituri. An example of one shortcoming residents wish to realize but cannot is to be able to wash their hands with soap and water or with 0.05% chlorine when in contact with others suspected of having EBV disease during outbreaks, but for many, access to these standard hygiene products for infection control may not be possible to obtain for a variety of reasons. Some of these reasons include lack or resources, inaccessible geographic locations, poor state of health, disability, and lack of transportation.

Call for Transparency and Better Healthcare

Outsiders and international officials in charge of the outbreak response effort may be quite out of touch and unaware of local conditions faced by the communities on a daily basis. Random or surprise visits in addition to well-meaning students performing short-term learning experiences also known as “voluntourism” to humanitarian crisis zones may actually be resented in the long-run by local residents as well as local workers who are not compensated nearly the same amount as their counterparts from the Global North. While large amounts of money have been spent on the current Ebola response effort, local communities in afflicted areas in the DRC have been suffering for years regardless of outbreak status and feel as though no significant efforts beyond outbreak assistance have been made to help them out of chronic states of infectious disease that affect a much larger percentage of the population in general.

What people are seeing is not any outcome or end in sight for this current and future suffering. They see the sick being hurried away by people in strange outfits and ambulances, and waking up to more of the same day after day in fear that they may be next. They have their loved ones suddenly removed from them and not allowed one last kiss before they are sprayed with chlorine and wrapped in plastic bags. They stand in silence and perhaps witness from a distance what they believe is an undignified burial and cruel disposal of their loved one’s belongings into a smouldering fire. At this point we need to empathize with the community and realize that researchers have come and gone and most often left nothing behind for them upon which to build a basic, thriving healthcare system. Most of this population has no access to internet and finding any data that may have been collected from them for the purpose of research may be difficult to obtain, translate, and understand. Thus it is also a priority to communicate all activities and all outcomes performed during this outbreak back to the community as part of the initiative to better understand the needs of this population beyond Ebola virus outbreaks and to prepare for future outbreaks as they are inevitable.

Survivors Cries

While huge strides have been made in containing Ebola and treating patients since the West Africa epidemic, the question of trust – at the various levels of family, community, local, and international actors – remains hugely important and difficult today in Congo.

As Nurse Kadija Kanu states in the documentary “Survivor” which was shot in Sierra Leone during the West Africa EVD outbreak that began in 2014, “We have been out in these streets sacrificing our lives and they use us like a tool.” When referring to international humanitarian officials, she asks, “When Ebola started, where were you?” It has a reached a stage where local health workers are wondering why the international community responded to Ebola and not to the many other diseases that have taken lives in their communities. “This is why it is difficult to build community trust,” she said.

Conclusion

lets all learn from our past mistakes, lets take a step back and think where we went wrong, lets involve the communities in our discussion and agreements, for us to bring the cases to zero , we need the community more than they need us .

The fight goes on.

References:

https://us13.campaign-archive.com/?u=89e5755d2cca4840b1af93176&id=49295e7bfc (MoH)

https://www.statnews.com/2019/04/12/the-data-are-clear-ebola-vaccine-shows-very-impressive-performance-in-outbreak/ (vaccine efficacy)

https://www.nature.com/articles/d41586-019-01432-y

https://relay.nationalgeographic.com/proxy/distribution/public/amp/science/2019/04/worlds-second-biggest-ebola-outbreak-still-raging-heres-why-hot-zone

https://www.cdc.gov/ncezid/stories-features/global-stories/ebola-reservoir-study.html

https://reliefweb.int/report/democratic-republic-congo/eastern-drc-tens-thousands-forcibly-displaced-surge-violence

https://www.who.int/csr/disease/ebola/training/safe-burials/en/

https://wsbt.com/news/health/un-congo-should-exceed-1000-ebola-deaths-on-friday

Lancet Editorial Volume 7 Issue 5 PE533, May 1, 2019

The true meaning of leaving no one behind

The Lancet Global Health

DOI: https://doi.org/10.1016?S2214-109X(19)30176-7