Ending an Ebola outbreak in a conflict zone
On 1 August 2018, the Ministry of Health in the Democratic Republic of the Congo (DRC) announced that the country was facing its 10th outbreak of Ebola virus disease . This time the outbreak was occurring in North Kivu, an area long-affected by a complex conflict. It took nearly two years to end the outbreak, during which time responders would face the double threat of a deadly virus, and violence.
Ebola virus disease can be fatal on its own. The virus is transmitted to people from wild animals and spreads through human-to-human transmission. The fatality rate is around 50% – but when people with Ebola are unable to access treatment it can rise to as high as 90%.
The North Kivu, South Kivu and Ituri outbreak was the second largest in history and had a fatality rate of 66%.
Outbreaks begin and end with communities. It was the engagement, acceptance, hard work and leadership from affected communities that helped to end the outbreak .
At its peak, 16 000 local frontline responders worked alongside WHO in support of the Government-led effort to end the outbreak. WHO deployed almost 1600 epidemiologists, logisticians, anthropologists, field coordinators and other specialists, each spending an average of 200 days working in the field.
Ebola in a conflict zone
Responding to an Ebola outbreak requires people on the ground, working directly with affected communities and travelling throughout the region. This work was highly dangerous given the infectious nature of the virus, and was made exponentially more so when carried out in an area beset by violence.
This map shows DRC's nine previous outbreaks in grey.
The 10th Ebola outbreak began in the provinces of North Kivu and Ituri Provinces in DRC. It was the area’s first known Ebola outbreak. Some cases were also recorded in South Kivu and in neighbouring Uganda.
An 11th outbreak is currently active in Equateur province.
The first cases in the outbreak were recorded in the Mabalako town of Mangina in May 2018.
By August the virus has spread to the neighbouring zones of Beni, Mandima, Oicha, Butembo and Masereka.
A contact tracing team at work in Beni © WHO
Between the first case of the outbreak, which investigations revealed likely occurred in May 2018, and the last case in May 2020, Ebola was recorded in 29 DRC health zones.
Active conflict surrounded and directly impacted the response. There were at least 420 attacks on health facilities, killing 11 and injuring 86 health care workers and patients.
Assessing damage after an attack on an Ebola treatment centre in Butembo © MSF
Over 3580 health structures were part of the infection prevention and disease control effort.
Logisticians and local teams set up 11 Ebola treatment centres and 25 transit centres amidst ongoing conflict.
Treatment centre under construction © WHO
Alerts and testing
The response to the outbreak centred on finding, isolating and testing people suspected to have Ebola in order to stop the virus from circulating in communities. It was also critical to get sick people to treatment as soon as possible in order to improve their chances of survival. At the height of the outbreak, up to 6000 alerts for people who were potentially exposed to Ebola were reported daily; each had to go through a process of investigation.
DRC is a large, landlocked country. As such, monitoring travellers in and out of affected regions in DRC was a huge undertaking. During the nearly two-year long outbreak, across 109 active points of entry there were 181 million traveller screenings. As a result of these screenings, 30 people with Ebola were detected and brought for treatment. Preventing them from onward travel limited the geographic spread of the outbreak.
The timeline
The following graphic begins in May 2018 and advances down the page. Streams of colour represent monthly Ebola case counts in different health zones. The wider the stream, the more cases of Ebola reported during that month.
Press the button to switch the view to monthly test counts, and hover over for more detail. Note the differences in scale. Cases peaked in April 2019 with 447 cases. Testing peaked in January 2020 with over 17 000 tests.
WHO streamlines
Contact tracing and vaccination
In responding to an outbreak of a highly infectious disease , tracing the virus’s movements is crucial to preventing further transmission.
When a person falls ill with Ebola, all those they've recently been in contact with are at greater risk of getting sick. These “contacts” need to be monitored closely for 21 days for any potential symptoms so that they can be isolated and treated quickly if they fall ill with the virus. Contact tracing also allowed those who were close to a person with Ebola to be swiftly vaccinated against the disease.
Hundreds of local responders were trained in contact tracing and administering vaccines . This outbreak was the first in which an Ebola vaccine was used on such a grand scale. For each confirmed case of Ebola, up to 200 contacts, contacts of contacts and third-degree contacts were registered. In total, more than 300 000 people were vaccinated.
Once a case is suspected, contact tracing and monitoring begins.
The 'first ring' encompasses all those who may have had direct contact with the patient.
The 'second ring' encompasses those in direct contact with the first ring, like healthcare workers and neighbours.
The 'third ring' encompasses contacts of the second ring, 3 degrees of separation from the suspected case. Given Ebola's highly infectious nature, vaccination extended to the third ring.
Patient care
Care for people suspected and confirmed to have Ebola was meticulously undertaken. This outbreak was the first time that all patients coming to any treatment centre had the same level of basic supportive care , and the first time patients were provided with access to investigational treatments . Innovative treatment centres were specially designed to allow for the best care with the least chance of transmission between patients and health workers.
In Beni, a treatment centre was built to test those suspected of having Ebola, as well as isolate and treat those who tested positive for the virus. This treatment centre was run by the Alliance for International Medical Action (ALIMA) and supported by the Ministry of Health, WHO and partners.
Patients arrived at the camp by ambulance and were tested for Ebola. Stable patients entered the suspect zone to await test results.
Patients exhibiting strong Ebola symptoms and those who returned positive tests would be closely monitored and treated in the red zone. The red zone consisted of 9 biosecure emergency care units called CUBEs .
In the event of a person's death from Ebola, families would be informed and the body would be transported to the mortuary before being safely buried. Families were instructed about special safety precautions to follow at the funeral in order to prevent infection.
Once a patient stabilized, they entered the yellow zone where treatment continued but medical staff numbers were fewer.
Patients nearing the end of their treatment entered the green zone. After 2 negative test results were recorded, the patient could return home.
The CUBE
The CUBE is a self-contained and transportable care unit developed by Dr Richard Kojan and the Alliance for International Medical Action (ALIMA) for treating highly infectious illnesses. With transparent walls, healthcare workers could safely monitor patients without increasing their own exposure to the disease. Clear walls also enabled patients to communicate with loved ones throughout treatment.
Personal Protective Equipment
Ebola outbreak responses require more than people, they require equipment . And lots of it. Ebola is transmitted through human-to-human contact. In past Ebola outbreaks, healthcare workers have frequently been infected while treating patients.
Even after a patient has died, their body remains highly infectious, creating the need for vigilance beyond death from the disease. Safe and dignified burials , spearheaded by Red Cross and National Civil Protection, were carefully and respectfully undertaken by responders in full PPE. WHO facilitated the manufacture and delivery of millions of PPE units.
In order to lessen the risk of transmission, PPE is required for the entire body to limit skin-on-skin contact between responders and patients.
Caring for survivors
The recovery from Ebola extends far beyond the treatment centres. People who have tested positive for Ebola must be monitored with monthly checkups for up to 18 months after completing treatment.
Long after an outbreak has ended, the effects of Ebola will be felt by those that lost loved ones to the disease and those whose bodies are still recovering.
Community
The work done and sacrifices made by affected communities stopped Ebola from spreading globally. Residents shared their knowledge by constructing maps of the region, teaching responders about cultural traditions and expectations, and assisting with education around vaccinations and treatment.
As with all fatal diseases, prevention is better than a response. The vaccination of more than 300 000 people played a huge part in ending this outbreak. With access to adequate treatment, the mortality rate for Ebola can drop down to as low as 30%.
In June 2020, mere days before the 10th outbreak was declared over, the 11th Ebola outbreak in DRC was declared by the Ministry of Health. Located in Equateur province, the outbreak is ongoing and WHO is supporting the Government-led response.
The race to stay one step ahead of Ebola continues.
Hand-drawn map of Butembo health zones by © WHO
For more information about Ebola, see here .
For more information about this response, see here .
