Ebola in DRC: One year into the outbreak

NAIROBI — As the Ebola outbreak in Democratic Republic of the Congo crosses the one year mark — with cases reaching over 2,500 and Rwanda closing its border with DRC as fears loom about the potential geographical spread of the virus — Devex asked Ebola responders to reflect on the response over the past year.

Some of the stories had a tinge of “what could have been” — if only the response had placed more emphasis on understanding the different contexts and gaining the trust of people in the communities from the beginning. Some were motivational, and are a testament to the rigorous work on the ground, while others recall moments of violence and difficulty.

The timeline below marks some of the turning points of the 12-month long efforts.

Aug. 1, 2018: A new outbreak

DRC’s Ministry of Health declared an Ebola outbreak in North Kivu and Ituri provinces — the 10th Ebola outbreak in the country’s history, but the first in this volatile region.

Then WHO regional emergencies director for Africa, Ibrahima Socé Fall, recalled how unprepared the region was for Ebola. Upon the World Health Organization team’s arrival in Mangina in North Kivu, one of the first things it did was to decontaminate the main hospital, which was becoming an Ebola infection zone.

Many organizations were shocked by the declaration as they had only just finished responding to a separate outbreak in Equateur Province. There were heightened concerns about this new outbreak taking place in a conflict-affected area with massive displacement and protracted humanitarian needs. North Kivu is home to dozens of armed groups.

“It's the first time Ebola has occurred in such a context so I think we were already pretty worried from the beginning,” said Michelle Gayer, International Rescue Committee’s director of emergency health.

In retrospect, many responders think they could have placed more emphasis on understanding the different community contexts in the region and gaining people’s trust from the start, which continues to be a challenge.

Aug. 8, 2018: Vaccination campaign begins

A campaign began to provide an experimental vaccine to high risk populations, using a “ring” approach, which involves immunizing contacts of those who have contracted the virus, and contacts of those contacts. While still unlicensed, the use of the vaccine was justified under “compassionate use.” The vaccine was also used during the outbreak in Equateur. Clinical trials for the vaccine were held during the 2014-2016 West Africa Ebola outbreak.

Aug. 11, 2018: Tedros visits epicenter

WHO Director-General Tedros Adhanom Ghebreyesus visited Mangina, the original epicenter, in Beni territory a week after the outbreak was declared.

“People were trying to tell Dr. Tedros: Don't go to Beni. Don't spend the night in Beni. He said, ‘well my life is not superior to the staff’s life, I will spend the night in Beni.’ He stayed for two days and ... I think it was really, really inspiring for the team to see the DG spending the night and coming back … It kept the team very motivated,” said WHO’s Fall.

Aug. 15, 2018: CUBE model

ALIMA opened an Ebola treatment center in Beni equipped with biosecure emergency care units or what the organization refers to as “the CUBE.” Anthony Bonhommeau, ALIMA’s head of emergency operations, said it brought a “big change” as it allowed both medical and psychosocial teams to see each patient 24 hours a day. It also allowed patients to have closer interactions with their doctors and families without the risk of transmission.

Sept. 4, 2018: First case in Butembo

The first Ebola case was discovered in Butembo, about 36 miles from Beni. When cases in Beni declined, there was a rise in cases in Butembo and Katwa, said Trina Helderman, senior health advisor at Medair. In response, partners moved locations, leaving behind less capacity in Beni — which led to an increase in caseloads.

The response has often been centered on “chasing to put out fires rather than doing the necessary preparedness activities,” said Benjamin Kaufman, program manager at Mercy Corps. 

Dec. 26, 2018: Excluded from general election

The government announced that areas of Butembo and Beni could not participate in the December national election in order to prevent transmission of the virus at the polls. That fueled a perception in the region — known to be an opposition stronghold — that “Ebola is something political,” said Trish Newport, Médecins Sans Frontières’ deputy program manager for the Ebola response. It was a “big turning point” in the response, she said.

Prior to the elections, rumors were already circulating that the government had created the outbreak to stop the elections, and that it was meant to “perpetuate the termination” of the Nande people, an ethnic group that lives in the region, Newport said.

On the night of the announcement, health centers were destroyed and looted, and organizations including MSF, International Rescue Committee, and ALIMA had to evacuate many of their staff.

Feb. 22, 2019: Return to Beni

Ebola returned to Beni after 23 days, becoming the epicenter of the outbreak once again.

“This is very worrying for us because it is a reversal of gains that we have made and it requires going back to the drawing board in terms of understanding what needs to be improved in order to avoid the same situation in other areas that we are recording successes,” said Tamba Emmanuel Danmbi-saa, DRC humanitarian program manager at Oxfam.

Feb. 24, 2019: Attacks on MSF

An MSF-run Ebola treatment center in Katwa was attacked, followed by another attack a few days later in Butembo. These events led the organization to suspend operations in the Butembo, Katwa, and Biena region, and forced it “to breathe and reflect and really think about how we want to move forward,” Newport said.

Unable to ensure the security of its staff or patients, the organization has not yet returned to Butembo and Katwa — where WHO and partners such as ALIMA took over — but it has continued operations in other areas.

March 7, 2019: Lack of community engagement under spotlight

MSF President Joanne Liu publicly spoke about the lack of community engagement, use of coercion, and militarization of the response. Her comments, according to Newport, were “not appreciated by everybody.”

“I think it hadn't been being talked about so much before that. And so while not everyone was happy that we said it, I also think it facilitated the opening of a dialogue about it,” Newport said.

March 25, 2019: 1,000 cases 

The number of Ebola cases hit 1,000. “The overall feeling was that we were containing it within North Kivu and Ituri. There was a sense, at least from some partners, of cautious optimism. That vanished in the following months when we jumped from 1,000 to 2,000 cases,” said Dr. Emanuele Capobianco, global director of health and care at the International Federation of Red Cross and Red Crescent Societies. 

April 19, 2019: WHO doctor killed

Dr. Richard Valery Mouzoko Kiboung, an epidemiologist deployed by WHO, was killed in an attack in Butembo University Hospital. The incident highlighted, once again, the issues around community engagement and security.

“These people came into the facility and shot him,” said Michelle Gayer, IRC director of emergency health. “And so all our staff, national and international, felt very vulnerable because [they felt that] … just because they were responding [to] the Ebola outbreak, [they] were being targeted.”

May 7, 2019: Vaccine expansion

WHO's strategic advisory group issued recommendations to expand vaccine coverage, adjust the dosage to ensure its continued availability, and offer an alternative vaccine to those at lower risk of infection who reside within affected health zones.

May 23, 2019: Response coordinator appointed

David Gressly was appointed United Nations emergency Ebola response coordinator. "For me, the most important step that I've seen to-date was the appointment of Gressly so that you have a focal point," said USAID Administrator Mark Green at a press roundtable on Ebola in Nairobi.

May 29, 2019: Response scales-up

The U.N. Inter-Agency Standing Committee voted to activate the IASC Humanitarian System-Wide Scale-Up Protocol for the Control of Infectious Disease Events.

“The way the government of the Democratic Republic of the Congo has always dealt with Ebola epidemics, was the idea that this is going to be over in three months,” said Mercy Corp’s Kaufman. The scale-up helped to change that mindset and expand the focus of the response to other health and humanitarian needs.

June 4, 2019: 2,000 cases

Ebola cases hit 2,000. Responders called this a “phase of exponential growth,” and stated that it gave rise to the fear that it may lead to an even more severe phase.

"It took 224 days to move from the zero case to 1,000 cases. [However] It took only 71 days to go from 1,000 cases to 2,000 cases. So the numbers doubled in one third of the time," said IFRC’s Capobianco.

June 11, 2019: Cross-border case

Uganda confirmed the first cross-border Ebola case — a 5-year old boy who had crossed over from DRC with his family. There were two other cases in Uganda imported from DRC — the 5-year old boy’s grandmother and brother. However, humanitarians remained optimistic about the ability to limit the cross-border spread. “If I had to pick of all the countries in the region who are best prepared, I would put Uganda at the top,” said Mercy Corps’ Kaufman.

July 14, 2019: First case in Goma

The first Ebola case was confirmed in Goma, the capital city of North Kivu, a major transportation hub and city of about two million people. The infected man was a pastor who had been moving around the region on an evangelical mission. It is the biggest urban center to be impacted by the outbreak.

“When we heard about the case in Goma we were not surprised, but it was concerning ... It was also an acknowledgement that we have limited capacities. We don’t have enough people, organizations or systems in place,” said Medair’s Helderman.

July 17, 2019: WHO declares an international health emergency

The Goma case was another turning point in the response, said WHO’s Fall, who since became WHO assistant director-general for emergency response. It led Tedros to reconvene the emergency committee for the fourth time to advise on whether to declare the outbreak a public health emergency of international concern. This time, the declaration was finally made.

Many health experts welcomed the declaration, which they argued was long overdue, to help raise the profile of the outbreak and mobilize more international financing. But there had also been concerns that it could trigger border closures and trade restrictions, which could hurt DRC's economy as well as the response.

WHO has argued the declaration is not tied to fundraising, instead stating that the decision was prompted by the spread of the disease to Goma, the recurrence of “intense transmission” in Beni, and the assassination of two Ebola workers the previous week.

July 22, 2019: Health minister resigns

DRC Health Minister Oly Ilunga resigned, shortly after President Felix Tshisekedi had set up a multisectoral committee that removed power over the response from the Ministry of Health and transferred it to the president’s office. This help signalled that the situation in the region is not just about health, but broader, said IRC’s Gayer.

July 30, 2019: Second case in Goma

A second case of Ebola was discovered in Goma — a man who arrived in the city from a mining area having passed through the epicenter of the outbreak on his way home. Following his death, his daughter also tested positive for the virus in Goma.

“As in the previous case in Goma, we need to understand how many contacts may have been infected. We will need a few weeks to determine how impactful this case will be in the overall trajectory of the epidemics,” Capobianco said.

This new case shows “the devastating potential for it to spiral out of control,” according to a press release from Oxfam International.

On Aug. 1, Rwanda closed its border with DRC.

Moving forward

While efforts are focused on containing the outbreak, experts said areas for improvement remain — including increased vaccine access, increasing the number of responders, a push for decentralizing the response, better dialogue with communities, and building preparedness efforts in at-risk areas.

“What I hope will happen is that there's better access to the populations at risk because the vaccine has been shown to be very effective. I also hope that care for ... [suspected] patients, is brought closer to the communities,” said MSF’s Newport.

WHO’s Fall underscored the need to have both response and preparedness efforts in place, and for more partners to step in to help.

“Some people are restricted by the security measure but … we have areas where we don’t have Ebola at this time, and where security is better. We can have more partners doing capacity on preparedness and readiness over there,” he said.

Aug. 1, 2019: This article has been updated with news of Rwanda’s border closing and the new role of WHO’s Ibrahima Socé Fall.