After 23 months, the longest and deadliest Ebola outbreak to hit the Democratic Republic of Congo has officially ended, Congolese authorities have announced.
It is now 42 days – double the virus’s three-week incubation period – since the last patient was discharged from an Ebola treatment centre, signalling the end of an epidemic that has infected almost 3,700 people.
Two thirds of those who caught the haemorrhagic fever died, with women and children worst hit – making up 56 and 28 per cent of the 2,280 fatalities respectively.
But as this outbreak in in North Kivu and Ituri in eastern DRC concludes, the 11th has already started some 600 miles away in Equateur province.
There the disease has now spread to Mbandaka, a city of 1.2 million people on the banks of the river Congo, and Bolomoba, 150 miles away. So far 23 cases have been found and 13 people have died – it's the third Ebola outbreak in as many years.
Today, though, the DRC and its international partners are celebrating a slither of long awaited good news. Hopes that the virus had finally been defeated were shattered back in April when, just three days before the World Health Organization was due to confirm the end of the outbreak, a 26-year-old electrician tested positive and a new cluster of cases was identified in the city of Beni.
This time, though, the 42-day deadline without new infections has held, the DRC's health minister Longondo Eteni announced today.
“This wasn't easy and at times it seemed like a mission impossible,” added Dr Matshidiso Moeti, WHO Regional Director for Africa. “Ending this Ebola outbreak is a sign of hope for the region, and for the world, that with solidarity and science and courage and commitment, even the most challenging epidemics can be controlled.”
But there are concerns that the unprecedented attention on North Kivu and Ituri will dissipate in the aftermath of the epidemic, as resources are shifted to tackle the world’s largest measles outbreak, a new Ebola epidemic on the other side of the country, and Covid-19. The country has identified 6,200 coronavirus cases and 142 deaths, though testing rates remain low.
According to an International Rescue Committee report published today, the number of people in need in the affected provinces has grown more than 250 per cent since the start of the Ebola outbreak, from 1.2 to 4.3 million.
“Today is good news for the population, but the international community should be mobilised to keep supporting them,” said Dr Michel Yao, head of the WHO Africa’s emergency operations programme manager. “We need to ensure that people have access to at least the minimum to live and work – insecurity and other health issues, like measles, are taking more lives than Ebola.”
This Ebola outbreak has not been the worst in global history. That grim title goes to the West African epidemic between 2014 and 2016, which saw more than 11,000 fatalities.
But it has been the most challenging – North Kivu and Ituri are in the midst of humanitarian crises after decades of conflict. Despite two effective vaccines, new treatments and additional tools to protect health workers, including the ‘Ebola cube’, efforts to contain the virus were hampered by violence and mistrust.
“The population was already very traumatised after years of conflict, so there was an existing level of distrust towards outsiders,” Alex Wade, head of mission for Médecins Sans Frontières in DRC, told The Telegraph.
“People also felt neglected – they were already suffering from many health problems and conflicts without international, sometimes even national, attention. So when Ebola came along and you had all these resources flooding into these areas, of course it created resentment.”
Discontent came to a head in early 2019. In February two Ebola treatment centres were burned to the ground, allowing the virus valuable space to spread. Then in March Richard Valery Mouzoko Kiboung, a WHO epidemiologist, was killed during an attack on a health facility – in total 11 members of the response team have been killed and 86 injured.
Growing insecurity raised questions about whether the outbreak could ever be contained. “These were all horrible moments, they made us step back and reassess,” said Gillian McKay, an Ebola expert at the London School of Hygiene and Tropical Medicine who worked in North Kivu during the outbreak.
“Clearly we were not listening to the community and their needs if we were having this extreme level of pushback. But protocols were changed after responders listened to the locals, to understand their concerns and complaints. I think the big lesson will be the need for a two-way communication system.”
Those lessons are already being applied some 600 miles away in Equateur province, where an unrelated Ebola outbreak was identified earlier this month. There are fears that the disease could spread rapidly as the region is large infrastructure often poor.
Dr Yao said involvement of local communities and staff was being prioritised in Equateur to build capacity and cooperation– and ensure the Ebola response was part of a broader health system, not separate.
“We should not take it for granted that having all these new innovations will prevent an outbreak – they must also be accepted by the local population,” he said.
Response teams have already vaccinated 5,000 people against Ebola, using a ‘ring vaccination’ strategy used during the North Kivu and Ituri outbreak. In eastern DRC some 300,000 people were immunised with a jab developed by Merck, which was fully licensed at the end of 2019. A second vaccine, made by Johnson & Johnson, was later used during a clinical trial in the field.
Large clinical trials were also conducted to test whether four new treatments could reduce the risk of dying after contracting Ebola. Two antibody-based drugs were found to be so effective that scientists said the virus was no longer an “incurable disease”.
“It’s quite amazing that in this challenging security context these trials were able to successfully take place,” said Dr Yao. He said the strategies used are now underpinning key aspects of trials for Covid-19 treatments and vaccines.
Dr Tedros Adhanom Ghebreyesus, director general of the WHO, added that the public health measures used to stop Ebola should be the “backbone” of the Covid-19 response in every country – especially “relentless contact tracing”. At the height of the epidemic in North Kivu and Ituri more than 20,000 contacts were tracked every day, 80 per cent of potential cases.
“It is more or less the same that strategies that we are using and the same methodologies... to fight against Covid,” said Dr Eteni, the DRC's health minister.
Dr Tedros also reiterated his calls for universal health coverage. “Ultimately, the best defence is defence against any outrages investing in a stronger health system,” he said.
New Ebola innovations will, though, be essential for the DRC, where spillover events appear to be becoming more common, said Ms McKay. The new outbreak in Equateur is the 11th known epidemic since the virus was first identified in 1976, but the third in as many years.
“Whether the virus is now endemic is a chilling question in my mind,” she said. “But endemicity implies you can never get rid of it. The outbreaks we have seen have all been unique, with a single transmission from an animal host, so I don’t think we’re at the endemic point yet.”
Dr Yao added: “We have a reservoir of the virus in wild animals living in the forest. I think the disease is becoming more frequent as humans are getting closer to the forest, often for economic activities like farming or mining.
“So the next step would be to vaccinate people in high risk areas in advance. But this will depend on supplies of vaccines and also financial resources available to us,” he said.
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