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DRC: Ebola crisis updates
On 11 June 2019, Uganda announced that a child had been positively diagnosed with Ebola, the first cross-border case since the outbreak began.
We are eleven months into the worst Ebola outbreak in the history of DR Congo, the second-worst on record, behind the West Africa outbreak of 2014-2016. Over 1,500 people have died, while more than 2,200 have become sick with the virus.
John Johnson, MSF Emergency Coordinator, gives the latest update from the area of the outbreak below:
Retrospective investigations point to a possible start of the outbreak back in May 2018 – around the same time as the Equateur outbreak earlier in the year. There is no connection or link between the two outbreaks.
The delay in the alert and subsequent response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (there are limitations on movement, and access is difficult) and a strike by the health workers of the area which began in May, due to non-payment of salaries.
A person died at home after presenting symptoms of haemorrhagic fever. Family members of that person developed the same symptoms and also died. A joint Ministry of Health/World Health Organization (WHO) investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak.
The national laboratory (INRB) confirmed on 7 August that the current outbreak is of the Zaire Ebola virus, the most deadly strain and the same one that affected West Africa during the 2014-2016 outbreak. Zaire Ebola was also the virus found in the outbreak in Equateur province, in western DRC earlier in 2018, although a different strain than is affecting the current outbreak.
Located in northeastern DRC, the North Kivu province is a densely populated area with approximately 7 million people, of whom more than 1 million are in Goma, and about 800,000 in Butembo. Despite the rough topography and the bad roads in the region, the population is very mobile.
North Kivu shares a border with Uganda to the east (Beni and Butembo are approximately 100 kilometres from the border). This area sees a lot of trade, but also trafficking, including ‘illegal’ crossings. Some communities live on both sides of the border, meaning that it is quite common for people to cross the border to visit relatives or trade goods at the market on the other side.
The province is also well-known for being an area of conflict for over 25 years, with more than 100 armed groups estimated to be active. Criminal activity, such as kidnappings, are relatively common and skirmishes between armed groups occur regularly across the whole area. Widespread violence has caused population displacement and made some areas in the region quite difficult to access. While most of the urban areas are relatively less exposed to the conflict, attacks and explosions have nonetheless taken place in Beni, an administrative centre of the region, sometimes imposing limitations on our ability to run our operations.
North Kivu is also a very rich region with a lot of natural resources (a third of its territory is dedicated to mining exploitation) which is also a political challenge as the province has the reputation of being an area that favours the opposition. The last elections were controversial with the population, who represents 10 percent of the DRC electorate.
Background of the epidemic
First declared in Mangina, a small town of 40,000 people, the epicentre of the outbreak appeared to progressively move towards the south, first to the larger city of Beni, with approximately 400,000 people and the administrative centre of the region. As population movements are very common, the epidemic continued south to the bigger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018 and cases have recently been found further south, in the Kanya area. Meanwhile, sporadic cases also appeared in the neighbouring Ituri province to the north, most recently in the Komanda health zone.
Overall, the geographic spread of the epidemic appears to be unpredictable, with scattered small clusters potentially occurring anywhere in the region. This pattern makes ending the outbreak even more challenging. Given the appearance of new confirmed cases ever further to the south, the risk of the epidemic reaching Goma, the capital of the province, is another cause for concern.
EXISTING MSF PRESENCE IN THE AREA
MSF has had projects in North Kivu since 2006. Today, we have regular projects along the Goma-Beni axe as follows:
- Lubero hospital: paediatric/nutrition care and treatment of sexual and gender-based violence.
- Bambu-Kiribizi: Two teams support local emergency room and paediatric and malnutrition in-patient departments, plus care and treatment of sexual and gender-based violence.
- Rutshuru hospital: MSF withdrew from the hospital at the end of 2017. However, in light of the volatile conditions in the region, we have returned to support emergency room, emergency surgery and paediatric nutrition programmes.
- Goma: HIV programme supporting four medical centres (including access to antiretroviral treatment).
More than 20 health zones across Ituri and North Kivu provinces have reported cases of Ebola.
We have new tools and improvements in the medical management of this epidemic, compared to previous Ebola epidemics, such as new developmental treatments; a vaccine that has given indications of being effective; Ebola treatment centres are more open and accessible for the families of patients; and provision of a higher level of supportive care. The outbreak has not spread to other countries or regions, which can be considered as a success.
However, ten months into the outbreak, the situation in the Ebola-affected areas of DRC is deteriorating and the number of Ebola cases continues to increase: more than 2,000 cases and more than 1,400 confirmed deaths have been reported to date.
The response has been marked by community mistrust towards the response; attacks on our Ebola Treatment Centres (ETCs) in Katwa and Butembo in February 2019 led us to withdraw from running these centres.
The mistrust and violent attacks against the Ebola response show no signs of abating; as recently as 25 May, a health worker was killed in Vusahiro while working to prevent the spread of Ebola. High levels of insecurity continue to hamper the efforts to control the epidemic and have a negative impact on its evolution: the violence further discourages people from seeking care in Ebola treatment centres, resulting in an increased likelihood of the virus spreading across the healthcare system.
Many people continue to die in the community – either at home or in general healthcare facilities – and significant numbers of new confirmed cases cannot be traced to an existing contact with Ebola.
The unrest, such as fighting between the army and armed groups in early May and the killing of a WHO doctor in April in Butembo, have brought many outbreak response activities to a standstill. Vaccination of contacts, contacts of contacts and frontline workers in Butembo and Katwa (the epicentre of the outbreak) is sometimes temporarily suspended because of threats to the safety of vaccination teams.
On 11 June, the Ugandan Ministry of Health and WHO confirmed a boy had tested positive for Ebola in the Kasese health zone, which borders DRC. It is the first cross-border case in the current outbreak.
The response to the current outbreak
The DRC Ministry of Health (MoH) is leading the outbreak response, with support from WHO. The MoH team sent to coordinate the response in Beni was dispatched from Kinshasa and is the same team that coordinated the response in Equateur province. The WHO emergency pool was mobilised in the area upon the declaration of the outbreak.
We believe it will not be possible to end this outbreak if there is no trust built between the response and the affected people. Response authorities and workers must listen to the needs of communities, restore people’s choice when it comes to managing their health, and involve the community in every aspect of the Ebola response. This includes integrating Ebola care in the overall provision of healthcare in the region.
In order to respond to people’s needs, earn their trust and improve our early detection of new cases, those responding to the outbreak need to support local health centres through training to identify suspected cases and manage isolation while people are waiting for their Ebola test results.
MSF has been involved in the outbreak response, working with the Ministry of Health, since the declaration of the epidemic on 1 August 2018.
Since our withdrawal from Katwa and Butembo following the attacks on our ETCs in February 2019, MSF is no longer running ETCs and is currently not providing care to confirmed Ebola patients.
We continue to undertake prevention and treatment activities of suspect cases, managing Transit Centres for suspected Ebola patients, and supporting health structures. Our activities include helping the healthcare system to provide support in general healthcare (beyond Ebola) such as treating common illnesses and improving water and sanitation, and implementing and strengthening triage and infection prevention and control activities (IPC).
In addition, our teams are reinforcing health promotion and community engagement in the areas where we are working. We are also working towards strengthening the disease surveillance system in our regular project areas, including in Goma.
MSF is currently running the following activities in the affected North-Kivu and Ituri provinces:
- In the city of Goma, MSF has been supporting emergency preparedness by reinforcing the surveillance system and ensuring there is adequate capacity to isolate suspected cases, including the construction of an ETC. We also have health promotion and community engagement activities in Goma and the surrounds.
- In the area surrounding Bunia, we are undertaking infection prevention and control measures in several health centres and transit centres in Komanda, Bunia, and Rwampara. We are also conducting health promotion and other awareness activities in partnership with communities.
- We are treating suspect cases in Bunia transit centre, with a 16-bed capacity.
- In Biakato, MSF teams are undertaking infection prevention and control and water and sanitation activities, plus identifying and treating suspect cases and providing treatment to people with non-Ebola illnesses.
- Across Lubero, Kayna and Beni, teams are undertaking triage and isolation of suspected Ebola cases, while providing infection prevention and control, and health promotion activities in hospitals and health centres.
- MSF teams are supporting the treatment of both non-Ebola illnesses and care to suspect cases at Lubero general hospital and five surrounding health centres, Kayna general hospital and five health centres in Beni.