The international president of Medécins Sans Frontieres (MSF, Doctors Without Borders) has issued a scathing analysis of the efforts to control the 7-month-old Ebola outbreak in the Democratic Republic of the Congo, saying the community hostility that is undermining the work is the fault of the response, not the people in the region, reports Stat News. And Dr Joanne Liu, who was in the affected area of DRC last week when two MSF-run Ebola treatment centres were destroyed by fire, said continuing the current approach – with ramped-up security – is unlikely to end the outbreak, which is already the second largest on record.
“We’re not sure that if we keep doing what we’re doing (it) will lead us to the end of things,” Liu said in Geneva, where MSF is based. Relying more heavily on security backup from local police, the Congolese Army, or UN peacekeepers in the region is increasing the perception that the Ebola response workers are “the enemy,” Liu warned. “The use of coercion adds fuel to this. Using police to force people into complying with health measures is not only unethical, it’s totally counterproductive,” she said. “The communities are not the enemy. Ebola is the common enemy.”
The report says MSF pulled its staff from Butembo and Katwa last week after the attacks on the treatment centres. The two cities are in the southern part of the outbreak zone, and are where most of the Ebola cases are now being found. The organisation is still staffing Ebola operations in other parts of North Kivu and Ituri, the affected provinces. MSF is in discussions about whether it will return to Katwa and Butembo, though Liu said the organisation needs to discern first whether those communities want the MSF staff to return.
The report says Katwa and Butembo have seen 344 Ebola cases to date, more than a third of the outbreak total. So far there have been more than 907 cases in this outbreak, with 569 deaths. Those cities are where the hostility to the response workers has been greatest. Liu said in the past month there have been at least 30 attacks on response workers and facilities.
According to the report, she noted that at this point in the outbreak, 40% of confirmed cases are still dying in the community, having shunned Ebola treatment centres. And in Katwa and Butembo in the past three weeks, 43% of new cases aren’t part of known chains of transmission, which means no one knows how they have become infected, she added.
Those are markers that the help being offered by the Ebola response isn’t what people feel they need, Liu said. She called the atmosphere towards the response “toxic.”
The difficulty in controlling the outbreak is ironic, she noted, because there are tools being used that people who worked on earlier Ebola outbreaks only dreamed of – experimental drugs and vaccine. “We were craving for vaccine” during the West African outbreak of 2014-2016, Liu said. One problem, she said, is the fact that the vaccine is being used in a ring vaccination approach, offered only to front-line workers and people who are known to have been in the virus’s path – known contacts of cases and contacts of the contacts.
The report says supplies of the vaccine, being developed by Merck, are limited, and it takes about a year to make new batches. So the World Health Organisation, which is overseeing the vaccination programme, is being cautious with its use. To date, nearly 86,000 people have been vaccinated in this outbreak.
Liu said people living in the outbreak zone do not understand why only certain people can be vaccinated. She argued using some of the other experimental vaccines – there are several, though they are not as far along in the testing process as the Merck one – would help. The report says she also advocated tailoring the response to the needs of the people, saying many don’t want to be sent to treatment centres where health care workers are unrecognisable under layers of protective gear. “It means treating patients as humans, and not biothreats,” Liu said.
There should be options for training people in the community in how to safely care for Ebola patients at home if they are adamantly opposed to going to a treatment cente, she argued. Likewise, people living in communities that Ebola response teams cannot easily reach because of security concerns could be trained on how to safely care for their sick, she is quoted in the report as saying.
Professor Yap Boum in the faculty of medicine, Mbarara University of Science and Technology and Professors Jean-Jacques Muyembe and Steve Mundeke Ahuka and Sabue Malungu in the faculty of medicine, University of Kinshasa, write in The Conversation that since August last year the DRC has been facing its 10th Ebola virus disease outbreak.
They write: “The virus seems to be gaining ground in this current outbreak in North Kivu. This despite extensive control measures being put in place. These were sufficient to end the 9th outbreak region of Equateur, 2500km from North Kivu. Part of the response has been to try out new drug regimes. As such, research is playing a critical role as efforts are made to establish their efficacy. But testing new vaccines is an arduous and time-consuming process. It’s also hard in the case of Ebola because there are a few different strains of the virus.
“In the race between research and Ebola, a vaccine candidate made by Merck is being tested. It’s part of new strategies implemented to limit the number of deaths. The vaccine was inherited from the West African Ebola outbreak between 2014 and 2016 when there were 28,600 cases and 11,325 deaths. The severity of the outbreak led the international community to vow that it would never happen again.
“The question is: why, despite the vaccine trials, as well as a range of other interventions, does the outbreak remain out of control in North Kivu?
“Factors contributing to this include violence in the region during the recent presidential election. Unrest in North Kivu led to the destruction of an Ebola Transit Centre earlier this month in Katwa. Then at the end of February two more centres were burnt to the ground in Katwa and Butembo. On top of this, armed rebel groups in the area are limiting people’s access and hampering the response. These challenges highlight the impact the community has on the success or failure of the Ebola response.
“The Merck vaccine that’s being used in the DRC has gone through several research studies. But it’s still not licensed and can’t be used in the same way as any other vaccines. The vaccine is being used on a compassionate basis to protect those most at risk of infection. This use of the vaccine requires that patients give informed consent, that data on safety including severe side effects be collected after every vaccine. This is not the case for licensed vaccines used in mass campaign vaccination.
“Since May 2018 more than 40,000 people have received Merck’s rVSV vaccine in Equateur and North Kivu. The rollout has been a joint effort run by, among others, the DRC Ministry of Health, Institut National de Recherche Biomédicale, the WHO and MSF. Early data suggests that the vaccine is contributing to limiting the spread of the outbreak.
“Other treatment options are also being tested alongside the vaccine. People who manage to get to an Ebola treatment centre and who test positive for the disease now have the opportunity to receive four new treatments being tried out. This is part of a clinical trial – the first of its kind – assessing the efficacy of these treatments. One of them was developed from the blood of a survivor of the 1995 Ebola outbreak in Kikwit, DRC.
“The efficacy of the new drugs will be assessed by comparing the number of deaths in each of the four treatments groups after 28 days. In all Ebola treatments centres, confirmed Ebola patients are asked if they want to participate. One of the drugs is then randomly selected and given to the patient who is followed for 58 days. Since 27th November 2018, 62 patients have participated in the trial. However, the study is currently on hold due to the recent attacks.
“As the virus is moving faster than the response, another vaccine will soon be evaluated in Uganda by a consortium including the London School of Hygiene and Tropical Medicine, Uganda Virus Research Institute, and Epicentre. Developed by Janssen Pharmaceutical, this works differently to the Merck vaccine. Results so far show that it can provide protection for one year and could be used in areas not yet affected by Ebola (preventively). For its part, rVSV could be used reactively – that is in response to contacts of confirmed cases.
“The Janssen vaccine targets Ebola Zaire, and when used with a booster 56 days after the first dose, it also targets Ebola Sudan, Ebola Bundibugyo and Marburg virus which have caused outbreaks in neighbouring Uganda and Sudan. The design of this new study is not yet finalised. But we believe that the 2 million courses of the vaccine that are available could play their part in the race between research and the Ebola virus.
“In Uganda 800 health care and frontline workers will receive the first dose of the vaccine followed by a second dose 56 days later. They will be followed for two years. It will take many years for the successful vaccines and drugs to be licensed. But, if they prove effective, they will improve responses to any new Ebola outbreaks.
“The hope is that, by the end of the current outbreak, the world will be better equipped to prevent, treat and stop Ebola virus disease. But science will win the race against Ebola virus only if communities are fully part of the response. Getting a deeper understanding of how people respond to crises such as Ebola will require others, such as anthropologists, to get involved too.”