ABIDJAN — Experts at the World Health Organization say they are hopeful that the availability of five experimental Ebola treatments will give a vital boost to efforts to quickly contain the current Ebola outbreak in the conflict-affected North Kivu region of the Democratic Republic of the Congo.
For the first time, therapeutic treatments will be administered alongside rVSV-ZEBOV — the Ebola vaccine used near the end of the 2014 outbreak in Guinea, and again during the May outbreak in northwest DRC — according to Ibrahima Socé Fall, WHO’s regional emergency coordinator for Africa.
The Democratic Republic of the Congo is well-rehearsed in responding to Ebola outbreaks — but as it faces its first outbreak in a conflict zone, humanitarians raise concerns about how quickly it can be contained.
While rVSV-ZEBOV has not yet been recognized by a regulatory committee as the approved vaccine for Ebola, it has proven effective in preventing the virus in past outbreaks and was deemed “effective” and “safe” by a WHO-led study.
In June, more than 3,300 Ebola contacts — those who have been in close contact with Ebola patients — were vaccinated during the outbreak in the Mbandaka region of DRC. “None of those vaccinated developed Ebola; all were protected,” Fall said.
During the current outbreak, however, responders are hoping that the addition of five previously unused Ebola therapeutics — including a treatment that was developed by the U.S. National Institutes of Health using the antibodies of an Ebola survivor from a 1995 outbreak — will add to response efficiency and success.
“A WHO expert committee reviewed all available Ebola therapies and recommended the ‘compassionate’ use of these medicines during outbreaks,” Fall explained. “Last time, we were ready to use them, but by the time the protocol was approved, the outbreak was over.” “Compassionate” use of medicines makes them available to patients in the absence of an approved alternative.
Clinicians and logisticians to administer the NIH treatment, mAb114, have been transferred to North Kivu and have already begun distribution. WHO Director-General Tedros Adhanom Ghebreyesus told journalists at a press conference earlier this week that medics were already treating five patients with the mAb114 treatment and that they were “doing well,” according to Reuters.
“It is too early to draw any conclusions and the observations and follow up continue as per the approved protocol,” WHO Africa Health Emergencies Programme spokesperson Sakuya Oka explained.
Several other experimental antiviral treatments — including Favipiravir, Remdesivir, ZMapp and REGN3470-3471-3479 — that were made available during the June Ebola outbreak had previously received approval to be distributed in the Mbandaka region. Now, treatments await similar approval from an ethics committee before distribution in North Kivu which are “expected shortly,” Oka said.
Because none of the treatments have been officially licensed, “compassionate” distribution of vaccines require patient consent and the opinion of treating clinicians to determine which therapeutic is given to each patient, Oka wrote in a statement.
Collaborative clinical teams supported by Médecins Sans Frontières, ALIMA and DRC’s Ministry of Health are working together to assess and decide which protocol will be used for each patient, Fall added. Each treatment option also has specific requirements for cold storage, logistics, and monitoring that require approval to ensure the criteria are being fulfilled.
A combined vaccine response of ring vaccination and geographic targeting will focus both on specific contacts of Ebola cases, and on high-risk populations in affected areas, especially where security is unstable.
“When using geographic targeting, we will go to a village and vaccinate all people in the area, instead of trying to understand exactly who’s at risk or not, because sometimes it’s very difficult to know who’s at risk when taking into account the security situation,” Fall said.
To date, more than 200 frontline health care workers and contacts of Ebola cases have received priority vaccines. While the vaccine licensing process continues, an agreement between Gavi, the Vaccine Alliance and U.S. pharmaceutical company MSD for Mothers — the developer of the Ebola vaccine, rVSV-ZEBOV — has ensured that 300,000 investigational doses are available for global distribution.
Containing Ebola in a conflict zone
North Kivu is one of the most volatile conflict zones in DRC, with nearly 120 violent incidents since January in the six Ebola-affected health districts, according to Oka. Ongoing conflicts between armed groups and frequent attacks on civilians had forcibly displaced an estimated 1.15 million Congolese in the region at the end of last year. Of those, roughly half were newly displaced last year due to heightened violence.
“This region [is] overall at a security level 4, one of the highest in the U.N. security phasing system, so we are concerned about the security of all those involved [in] the response and the ability of populations to access care,” Oka wrote.
The epicenter of the epidemic is currently in Mangina health district, which still has fluid access and a moderate security level. However, Oka explained that immediately east is an inaccessible area. He said that timely, active surveillance during an Ebola outbreak is crucial to presenting a complete picture of the outbreak and being able to prepare nearby populations for its potential arrival.
“The problem is [that] where we don’t have access, if we are not getting alerts from those areas because the security situation is bad, then something might happen [and] we might be surprised,” Fall detailed further. “That’s why we want full access to all areas to make sure that we don’t miss any alert or cases, which is extremely important.”
WHO and supporting partners — MSF, UNICEF, the World Food Programme and the International Federation of the Red Cross and Red Crescent Societies — are receiving logistical guidance from the DRC-based U.N. peacekeeping mission, MONUSCO, to ensure staff safety when delivering aid.
Fall said in some cases, negotiation with armed forces could be possible: “If there is need to discuss with any specific group for access to an area, we will do it,” he said.
Ebola is endemic in DRC. This is the country’s 10th outbreak since 1976, although it is the first in a conflict zone, which brings greater logistical challenges. As of August 15, there have been 78 cases, including 51 confirmed and 27 probable.
Fall urged donors’ timely response to fully respond to the crisis. The required $43.8 million budget remains 27 percent funded.
“It’s important to get more donors because we have an outbreak that is concentrated in a specific area, so if we act fast enough we can control it in a reasonable time but it’s important to have all the means we need to act quickly,” he said.
Update, Aug. 17, 2018: This article has been updated to clarify the difference between treatments for Ebola and the Ebola vaccine used in the DRC outbreak, and to clarify that Gavi, the Vaccine Alliance and MSD for Mothers developed and licensed the Ebola vaccine, rVSV-ZEBOV.