Managing infectious diseases in DR Congo: lessons learned from Ebola

Abstract

DR Congo has long been associated with civil wars and political instability—such factors have not helped when dealing with the frequent outbreaks of serious infectious diseases in the country. Ebola virus disease, in particular, is endemic and has ravaged many areas of the country in several outbreaks since 1976 when the Ebola virus was first identified there. The 10th outbreak of Ebola, ongoing for 2 years in North Kivu since Aug 1, 2018, was particularly lethal as it took place during a time of active conflict, and claimed 2287 lives. And in June this year, just as DR Congo cautiously celebrated the end of the 10th outbreak, a fresh outbreak was declared in Mbandaka city and the Wangata and Bikoro Health Zones—at least 60 cases and 24 deaths have been reported by WHO from the 11th outbreak in these regions as of July 20, 2020. The latest Ebola outbreak adds further pressure to the country's overburdened health-care system that is already grappling with other infectious diseases. The world's largest measles epidemic has been ongoing in DR Congo since June, 2019, exacerbated by delays and coordination issues with vaccination campaigns, all of which have contributed to a heavy death toll—6779 deaths in 2019, and 783 deaths reported as of May 17, 2020, mostly of children. Additionally, there has been a surge in plague cases within the Rethy Health Zone in Ituri province: 43 cases of bubonic plague and two of septicaemic plague, with nine deaths, occurred between June 12, and July 15, 2020. The current global COVID-19 pandemic has also affected DR Congo, not only adding to the health-care burden itself (8625 confirmed cases and 196 deaths as of July 23, 2020), but also interrupting response activities for other diseases, such as disruption of measles vaccination campaigns. Infection with plague bacterium Yersinia pestis, Ebola virus, and measles virus can all cause severe disease and result in high mortality; therefore, early identification and treatment are essential. Although the 11th Ebola outbreak has arrived at a challenging time for the country, more is now known about the disease and the government seems to be better prepared and equipped for the fight. The rVSV-ZEBOV-GP vaccine has been administered to several thousand people, travel restrictions have been imposed between the country's provinces, and measures to identify, isolate, test, trace, and care for every Ebola case have been implemented, especially through providing community workers with a contact-tracing smartphone app. Additionally, community engagement and educating individuals has become an important part of the fight against Ebola, including teaching about the risks of pathogen transmission from wildlife-to-human (eg, via exposure to live or dead bats) and human-to-human (eg, during open-casket funerals of infected individuals) in a culturally sensitive way, which is crucial for overall control of the disease. It seems that the DR Congo's response to Ebola could provide valuable lessons on the management of other infectious diseases in the country. Emmanuel Lampaert (Médecins Sans Frontières, Kinshasa, DR Congo) commented “Ongoing engagement with the community, in combination with awareness, access, and continuity of care is essential.” He added, “We must make sure infection control measures are in place and set up screening in triage and isolation areas. Disease transmission must be prevented through the early identification and isolation of potential cases, as well as through the timely follow-up of contacts.” The previous Ebola outbreaks highlighted that measures to control transmission of a community-driven disease should involve the affected communities, and educate individuals about how they can protect themselves and others—for example, attending health centres for vaccinations, and self-isolation of contacts. In a country such as DR Congo where civilians might not fully trust the government or foreign aid workers, engagement with local leaders who already have the trust of the community might be more effective. David Heymann (London School of Hygiene & Tropical Medicine, London, UK) noted “In the Ebola outbreak […], contact tracing was not effective until trusted individuals from communities where infection was occurring worked alongside tracers to identify contacts and help them understand the need for self-isolation and reporting of symptoms”. Jeremy Rossman (University of Kent, Kent, UK) agreed, adding “There are many lessons that have been learned from responding to previous infectious disease outbreaks such as Ebola virus [disease] in the DR Congo. One is that community trust is essential for an effective response; there needs to be clear, consistent, and transparent communication of the situation, the risks, and the response”.