Ebola in Congo: What you need to know

Three years after the largest Ebola epidemic in history ravaged West Africa between 2013 and 2016, the second worst outbreak the world has seen is now spreading through parts of the eastern Democratic Republic of Congo (DRC).

With 2,868 infections and 1,926 deaths so far, the World Health Organization (WHO) declared the outbreak a Public Health Emergency of International Concern in July. But the good news is that unlike in West Africa, the disease is now preventable and treatable. In DRC, a whole arsenal of tools is on hand — including a vaccine and two remarkable therapeutics that have been found to dramatically improve survival.

Here are five things to know to better understand the latest North Kivu Ebola outbreak, from key international partners to the latest breakthrough in treatment and the sociocultural reasons that can make the delivery of treatment difficult.

1. DRC has a long history with Ebola.

Unlike Guinea, Liberia and Sierra Leone, which had never had an outbreak on their soil before 2013, the current outbreak is the 10th to hit DRC since the virus was discovered there in 1976. Since it began in August 2018, the outbreak has affected three provinces in eastern DRC — North Kivu, Ituri, and, as of last week, South Kivu province.

At the helm of the DRC-led response is Jean-Jacques Muyembe Tamfun, an acclaimed microbiologist and Ebola researcher with four decades of epidemic investigations behind him. Also the head of Congo’s National Institute for Biomedical Research, Muyembe is perhaps most famous for investigating the first ever outbreak of Ebola in 1976, in Yambuku, DRC — where, with only soap and water at his disposal, he collected blood samples from patients using his bare hands.

Muyembe took the reins of the latest outbreak in late July, after differences of opinion on vaccination strategy prompted the resignation of health minister Oly Ilunga, who had overseen the response for almost a year. Ilunga had opposed calls from a consortium of global health actors — including the London School of Hygiene and Tropical Medicine’s Peter Piot, who co-discovered Ebola, and Médecins Sans Frontières — to trial a second experimental vaccine in DRC. The consortium argued that introducing the additional vaccine to parts of the DRC where the disease has not yet spread would add an extra layer of protection and enable researchers to gather data on the vaccine’s efficacy. Ilunga disagreed, arguing that the two-stage inoculation (it requires two doses administered 56 days apart) would jeopardize trust-building efforts with local communities and complicate the existing ring vaccination strategy. For now, it is unclear whether the additional vaccine will be rolled out under Muyembe’s leadership.

2. Canada has been playing a key role in the response.

Around 180,000 people in North Kivu, including frontline health workers, have received an investigational Ebola vaccine, and it was made in Canada. The Merck rVSV-ZEBOV vaccine is still unlicensed, but preliminary results from the WHO show that it confers a high level of protection — around 97.5 percent efficacy.

The story behind the vaccine goes back to 1999, when few in North America had even heard of Ebola. Virologists Xiangguo Qiu and Gary Kobinger at the Public Health Agency of Canada’s National Microbiology Laboratory in Winnipeg began studying the virus, and soon realized they had what it took to develop a vaccine. Years of knockbacks from funding agencies — for whom Ebola wasn’t then a priority — followed, but the scientists doggedly pushed on, until in 2005 they published the first set of data: the vaccine was 100 percent effective on macaque monkeys. The government of Canada donated the vaccine to the WHO, and it was licensed to NewLink Genetics and Merck during the West Africa outbreak. After an experimental trial in Guinea revealed promising safety data, a subsequent ring vaccination clinical trial — which offers vaccines to the contacts of confirmed cases and the contacts of contacts — was rolled out in eastern DRC. Frontline health workers have also been receiving the vaccine.

Canada’s contribution to curbing Ebola goes beyond rVSV-ZEBOV. In May 2018, it announced a donation of $2.5 million in emergency humanitarian assistance to organizations responding to the more recent outbreak. This is in addition to other support for organizations such as the WHO and the Red Cross who work in DRC. Canadian health workers are also on the ground in treatment centres in North Kivu, and the Canadian-developed ZMapp drug (the only investigational therapeutic on the scene during the West Africa epidemic) served as the control arm in the 600-patient PALM clinical trial whose promising preliminary results were announced this last week.

Canada isn't the only international actor involved in the response to the outbreak. The UK, EU and USAID have also contributed, however there has been recognition that more needs to be done by all foreign partners, especially if compared to the response in West Africa.

3. There are now two curative treatments for Ebola.

Researchers announced the breakthrough news last week: the preliminary results of two investigative treatments being offered under the PALM trial (named for the Swahili expression “pamoja tulinde maisha,” which means “together save lives”) are so remarkable that some are hailing them as a cure.

The two game-changing therapeutics are REGN-EB3 — a cocktail of three monoclonal antibodies made by Regeneron Pharmaceuticals — and mAb114, a single monoclonal antibody developed from the plasma of an Ebola survivor at the US National Institute of Allergy and Infectious Diseases. They both work by blocking critical proteins in the Ebola virus and have been found to dramatically boost the odds of survival; when given soon after the onset of symptoms and in concert with supportive care, they are helping 90 percent of patients to recover. The treatments are administered intravenously, and in patients with low infection levels their impact is rapid; some patients are reportedly seeing their symptoms abate within just one hour. The only potential downside is that researchers think that patients treated with the monoclonal antibodies do not retain lifetime immunity from Ebola afterwards, unlike those whose immune systems defeat the virus alone.

The results of the PALM trial are exciting enough that the two other treatments in the trial — ZMapp and the antiviral drug remdesivir — have been dropped completely, and patients are now only being given either REGN-EB3 or mAb114.

(ZMapp may no longer be the best treatment option on hand, but the made-in-Canada therapeutic played an important role in the evolution of Ebola care by helping to pave the way for the framework that sanctioned the use of experimental therapeutics in an outbreak on compassionate grounds.)

4. DRC’s neighbours are implementing preventive measures.

Three cases so far have spilled across DRC’s border (and been subsequently contained) so neighbouring countries are on high alert and are increasing their own preventive measures. Uganda — no stranger to Ebola either, having seen three outbreaks in the past — has launched a two-year trial of a Johnson & Johnson vaccine in the southwest Mbarara district that flanks North Kivu. Burundi has also announced that it will begin vaccination with the rVSV-ZEBOV vaccine around its Gatumba entry point to DRC. Meanwhile, neighbouring Rwanda is implementing extended health checks at its border with DRC — a key crossing point for traders, as well as response organizations based in Goma, North Kivu’s capital — and there have been reports of intermittent border closures.

5. The curative treatments aren’t a silver bullet.

It would be easy to assume that because of the promising new therapeutics the outbreak will now taper off, but it’s more complicated than that. Fuelled by inequity, weak health systems, hierarchies of power, political instability and communication gaps, Ebola infects not only bodies but entire communities— and despite the vaccine and therapeutics, it is continuing to spread. Tackling it requires a multi-faceted approach; a cocktail of interventions that includes clinical care, epidemiology, community engagement and genomic sequencing, to name but a few.

Most importantly, the new therapeutics are most effective when given hours or days after the onset of symptoms, and they can only be administered in concert with good supportive care: that means IV lines, adequate health worker-patient ratios, and reliable access to resources and labs. Those were in short supply in West Africa, but they do exist in this outbreak; in fact there are even new tools and tech like bluetooth EKG machines and the transparent patient biospheres offered at treatment centres run by the Alliance for International Medical Action. Known as ‘CUBES,’ they allow relatives to see their loved ones, communities to witness clinical interventions, and health workers to monitor some aspects of patient care without the high-risk activity of donning and doffing personal protective equipment. Despite these new advances, there is still a pressing need to ensure a higher standard of supportive care at health facilities in DRC and other countries at risk of future Ebola outbreaks.

Community engagement is also a critical piece. Therapeutics only work when people are willing to receive them, and this outbreak response — like the previous one in West Africa — has been hampered by low trust between communities and responders. Organizations including the International Federation of the Red Cross and UNICEF have been partnering with communities to better understand their concerns and priorities, which are not simply the product of low education levels but of valid experiences. Because of inequities of power and health — not just within DRC but globally — many local people see Ebola as a get-rich-quick scam by the government and foreign responders. They don’t understand why health workers are more worried by Ebola than the just-as-fatal diseases that have cost their children’s lives: malaria, cholera and measles. And, like in West Africa, many people see health facilities as places you only go to die.

Add in the factor of active conflict, and you see why it is incredibly challenging for health workers to trace chains of transmission, reach vulnerable groups for vaccination, and persuade people to go to official centres for treatment. Their work is brave and dangerous; they’re carrying it out amid the constant threat of arson attacks and brutal killings. Hundreds of health workers have been attacked and several killed so far. Treatment centres have been burnt to the ground by community members who don’t trust their motives.

In this climate, it is estimated that up to half of all cases could be going undetected, so finding the right ways to reach people and build trust is key. The good news is that responders can now tell people the kind of news that transforms outlooks: if they go to a treatment centre early, they now have a 90 percent chance of recovering from Ebola. Five years ago in West Africa, that idea was unheard of.