It’s too soon to say the outbreak of Ebola that has infected 116 people and claimed 77 lives in a conflict-prone eastern region of the Democratic Republic of Congo is fully under control, but great progress has been made in learning how to contain and respond to such emergencies, according to the World Health Organisation’s response chief.
A month after Ebola emerged in the village of Mangina in restive North Kivu province, IRIN spoke with Peter Salama, the WHO’s deputy director-general for emergency preparedness and response, to find out more about the unique challenges this outbreak presents and to learn what has changed since the deadly virus claimed more than 11,300 lives in West Africa in 2013-2016.
Salama was optimistic that new, game-changing ways of tackling Ebola could help stamp out the current outbreak, Congo’s 10th since the virus was first discovered near the country’s Ebola River in 1976. However, he also cautioned that some of those tactics – vaccination, improved community engagement and, potentially, therapeutic treatment – are much harder to deploy in areas of severe insecurity, areas where it’s not always possible to get an accurate picture of new infections.
While the vast majority of cases in North Kivu and neighbouring Ituri province are in places where responders can operate freely, at least two have emerged in a town surrounded by a violent militia, making it much harder to get in, trace contacts, and vaccinate. Consequently, there is still a real risk, Salama warned, that the virus could spread into more dangerous areas or even to neighbouring states that – especially in the case of South Sudan – would be ill-equipped to fight it.
Here are selected excerpts from the interview, (edited for clarity):
IRIN: Do you have a full picture of the extent of this outbreak?
Peter Salama: I’d characterise our picture as fairly comprehensive, one month in. The major additional variable and complicating factor is the fact that it's taking place in an area that is highly volatile, from a security perspective. There are one million displaced people, out of the population of eight million of northern Kivu. Many of the areas to the east of the epicentre of major areas of operation are classified in the UN as security level four [red zones], and many of those areas are real blind spots because of the conflict in northern Kivu. There are no health workers, no health facilities. And so there's no real reliable source of information to give us the alerts of any potential suspected cases. But… I don't think we're missing any large cluster of cases in the area of northern Kivu because we have a large number of people and such a lot of outreach, such a lot of contacts with people at all levels from the community. It is entirely possible in the areas of highest insecurity however, we are missing a small number of cases somewhere.
IRIN: What’s different about the progression of this outbreak?
PS: Usually, in the past, particularly with DRC outbreaks, they have occurred in fairly remote rural locations, so they have almost in a sense been self-limited, where they have accelerated their [own] termination. Beni and Mangina, the two epicentres of this outbreak, have populations of around 40,000 to 50,000 people. Even Oicha, that town to the northeast of Beni where we've been particularly concerned about in the past week or so because it is on a road that is really a red zone, even that town has a population we estimate at about 40,000 people. So that more urban setting is a very different setting for transmission. It means that a far larger number of people can be infected quickly, that one super-spreading event can affect much larger numbers of people in urban areas than in a rural area. And the transmission dynamic can be very different.
It's too early to say whether the outbreak is turning around, but certainly there are some promising signs that the very high level of new case confirmation that we were seeing two or three weeks ago may be starting to show signs of decreasing, at least in the incidents of new cases. I'm cautious in making any claim that we've turned the outbreak around yet, and really the next one to two weeks will be quite critical in that regard.
The longer the outbreak goes, the more chance it will likely begin to spread to areas to the east, to the north, which are much less accessible from a security perspective.
The impact would likely be seen over the next one to two weeks in terms of how the epidemic curve responds to those response pillars: contact tracing, early identification of cases, isolation and care of those cases, the vaccination campaigns, the safe burials, and the community engagement to change behaviours. All of those response pillars are now reaching peak performance and we'd expect to see them having an impact now on the overall epidemic curve and outbreak trajectory.
IRIN: Looking ahead, what are the best- and worst-case scenarios?
PS: The best-case scenario is that over the coming seven to 10 days, we'll see that epi-curve really begin to tail off, and there's some promising data to suggest that in the last few days... So we limit the outbreak to its current geographical confines.
The worst-case scenario is that we see either cases across borders of Uganda, Rwanda, most concerningly South Sudan, which has very little infrastructure to deal with it, or Burundi, and we see cases in those very difficult to access security areas, [including] that far eastern hinterland close to the DRC-Ugandan border, on the DRC side.
IRIN: How has insecurity affected the response?
PS: We've been able to hold the epidemic into a radius of around 20 to 30 kilometres around Mangina and Beni, and that area is quite accessible at the moment to our responding people and agencies. Having said that, it's not without risk. So on Friday [24 August] in a place called Navivi, there was an attack reportedly by ADF [militia] against the Congolese army positions where 17 soldiers were killed (The Allied Democratic Forces is a rebel group with links to Uganda). That's about three kilometres from the airport, where we have staff coming in and out, and only four kilometres I think from an emergency operation centre in Beni... and the ADF overran that army platform, took all of the weapons, and clearly showed that they're able to mount a significant operation very close to the positions of the government and MONUSCO [the UN peacekeeping mission in DRC].
The road from Beni to Oicha is a red area so it requires us to use armed escorts of MONUSCO to reach Oicha. And we've had to do that over the past week. We have to travel sometimes with armed escorts and other times with armoured vehicles. We have to ensure that everyone has radios, has security, personal protective equipment. We have to call into a base radio station on any movement for any of our 200 staff. So it just causes a lot of complications and means a much costlier and more cumbersome operation.
But so far we can say it hasn't materially hindered the response, largely because we've managed to keep the confirmed cases, probable cases, suspected and contacts, within an area tightly confined in and around the two epicentre towns. Having said that, if the outbreak extends beyond that radius in any way, shape, or form, particularly to the east or the north, we're on much trickier ground...
So, for example, now we have 41 contacts we've been following in red zones. We've had to follow those contacts, give them mobile phones, if they didn't have them, to call in their temperature twice a day to a central location to ensure that there are health workers locally who are able to check in on them; and, again, to get phone reports in from those locations, and then to go in, if necessary only – and that would have to be expanded if of course the outbreak's geographical parameters expand. It could become much more difficult, and of course if there are a significant number of cases in these blind spots it would just delay our ability to potentially recognise new clusters of cases, and then of course to respond.
We had one test case though – which gives us some reassurance – in Oicha where it really did require us to go through at least the road which was a red zone and requiring armed military escorts. And despite the complication, we were still able to reach the cases within 24 hours and to begin vaccination within the same timeframe.
We are determined to find ways to stop this outbreak no matter where it hides and where it goes, but if it does enter into the most inaccessible, insecure parts of the eastern and northern part of North Kivu province, it's just going to make life much, much harder on the response and it's going to entail us finding even more creative ways to access any communities that will be affected.
IRIN: How has Ebola response evolved since the 2013-16 West Africa outbreak?
PS: I think it's a very different day for how we respond to Ebola and basically the measures such as activation of emergency response. Our incident management teams, the advancing of financing through our
contingency plans for emergencies – all of this happens now within hours of official declaration of [an outbreak], including the deployment of initial teams of responders. We also are very much implementing a no-regrets policy of really hitting hard and hitting early in these responses.
I think what we've seen is a real paradigm shift in how we approach two issues: vaccination and therapeutics… we’ve started to see vaccination as an intrinsic and integral part of Ebola response, which I think is a very positive new development, and we'll be able to hopefully model some of the impact that that's had over the last two outbreaks in terms of the evolution of these outbreaks.
IRIN: Is WHO reconsidering its guidance on giving this vaccine to pregnant women in the light of the recent op-ed on this issue?
PS: It's not a black-and-white issue at all... this is an experimental vaccine and it's using a live virus, and so if we were to use the Ebola vaccine in pregnant women, as an official part of the strategy... we would ethically be obliged to have a system that would allow us to follow up for adverse events throughout the entire pregnancy. So we have to be quite sure that from a feasibility perspective, we're able to meet that stringent ability to follow those adverse events for the nine months.
You can imagine in a situation like North Kivu, with a million displaced people, ongoing conflicts on all sides, a very weak if non-existent health system in some parts, that to be able to guarantee we're going to be able to follow up those women for nine months is not an easy thing to do. So this is where theoretical recommendations meet field realities, and we have to make sure that the risk-benefit analysis includes all of those field realities. The other thing that we need to take into account is that when you vaccinate in a ring and you achieve high coverage in that ring of contacts, as we've seen in the ring vaccination trial, we believe that will show up once this is formally written up in the Equateur use of the Merck vaccine as well, that of course we get to some extent… herd immunity.
We get some conferred immunity because most of the people in contact with their neighbours are now vaccinated because of their contacts. And so indirectly, we believe that also is helping some of the children and pregnant women in the area who may not be vaccinated themselves, to benefit from some level of protection. But overall we have to look at all of the data that's available. Mostly it's great literature at the moment from Merck, from some of the previous trials that have been done. And even though they are very small numbers, [we will] look in detail about how we can interpret that data to see, again, if the risks truly outweigh the benefits or vice versa. And that work is constantly under review by our scientific advisory group.
We've already got now 17 people who've benefited from some of these five [experimental] treatments. We hope there'll be more in the coming days who will benefit from that. And, hopefully, over time, with good research protocols, we will be able to show the impact of that.
For a very long time, as long as all of us have been responding since the late 1970s to Ebola, all we had to really offer communities was isolation, and information. We didn't have anything really concrete in terms of medical products to be able to say, okay, here's something that can prevent you, as a carer, who's been in contact with a patient with Ebola, here, here's a therapeutic drug that can really significantly improve your chances of survival if you were to contract Ebola.
Why is that important? It's important because it's a real confidence-building measure for us to be able to say to communities, please come early if you've got any symptoms that could be consistent with Ebola and seek help. And when communities begin to understand actually there's something very concrete that can improve their chances of having an infection prevented, or if they do get Ebola, surviving, that has a huge knock-on effect on community acceptance for all of our Ebola response missions.
IRIN: Has anyone who has been vaccinated developed Ebola virus disease?
PS: It’s entirely expected that there be a few cases of people who are vaccinated who get EVD [because] there's a seven-to-10 day window after you're vaccinated where you don't have immunological protection… because your body's making those antibodies. The Guinea ring vaccination trial with the same vaccine basically showed that after that 10-day window, the vaccine was literally 100 percent effective.
IRIN: Can we say the experimental treatments are working?
PS: There is some promising information on the drugs that have been used thus far, that they've been well tolerated, there haven't been very significant adverse events. And of course anecdotally we can say that some people have recovered. But it's too early to conclude anything on this.
If the number of cases ladder-up, and actually, even if they don't, we may initiate a multi-outbreak, multi-country research trial comparing in a more formal way over time. And if we don't get enough numbers... over time in many countries we’ll aggregate the data and under this research trial, and hopefully we'll be able to say more definitively, you know, x y worked and x worked better than y. That's really what we want to be able to do.
IRIN: Is there a bigger picture this outbreak feeds into?
The North Kivu outbreak in particular illustrates a particularly concerning dynamic – and we see this again in many fragile states – where the interplay of conflict, and the fact that it has undermined the development of social sector systems and health systems in particular… complicates any response. That confluence of factors is very much there. And when you add high-threat pathogens into the mix of humanitarian crisis in fragile states, you really have a toxic mixture that becomes very difficult to respond to.
Other examples of where that's occurring [include] of course polio, and the Afghanistan-Pakistan border as the major endemic reservoir of polio that remains as a key bottleneck to global eradication of polio. The cholera outbreak in Yemen is clearly adversely affected by the conflict in that country. And there are many other examples where that mixture of humanitarian crises, conflict, and high-threat pathogens is posing a new set of challenges to WHO and our partner agencies.
IRIN: What might be the broader benefits of the response to these recent outbreaks?
PS: We'd really like to use the learning from these outbreaks as an opportunity: we want to break this vicious cycle in places like DRC of having one outbreak after another. And it's not just Ebola – we've had outbreaks, currently actually in DRC, of vaccine-derived polio, and we've got cholera outbreaks current in eastern DRC as well. We've had yellow fever outbreaks recently, there have been measles and malaria outbreaks. So these are countries that are subject to almost a constant threat of outbreaks. And we really would like to use the attention that Ebola has brought the DRC to really work with the Ministry of Health, the international donor community, to really develop methods to really break the cycle once and for all and ensure that DRC, despite all of the constraints that we have in such a fragile context, is really able to, over time, develop the capacity to detect, prevent, and respond to these outbreaks itself.