Portrait of uncontrolled Ebola

The latest Ebola virus disease (EVD) outbreak has been a slow burn in the Democratic Republic of the Congo since the first official report in July 2018. With the wonderful benefit of hindsight, it now seems like the outbreak hasn’t really been under control for any extended period at all.

Being able to conceptualise how EVD is moving through the known chains of transmission has been harder in the more recent stages of this outbreak than in other recent ones. So when we frequently see surges in the number of new cases but no uptick in the number of people being vaccinated, we’re left to wonder at why that might be happening.

Release the chains

So are the new cases in each flare-up part of known transmission chains? If so, have the contacts and contacts of contacts have already been vaccinated – or offered the vaccine at least? Have the new cases occurred in areas of conflict where it’s too dangerous for healthcare workers to enter? Or, is there a bigger vaccine-refusal problem in some areas of increased case-finding than we can guess at from afar? It’s unclear.

What is clear, is that the time it’s taken to reach nearly every 200 newly confirmed EVD cases or deaths has been shorter and shorter.

We’ve never seen an extended period of time between one multiple of 200 and the next; the outbreak hasn’t been under control.

Uncontrolled Ebola virus disease. The time to reach the next 200 EVD cases in the DRC has been shorter than the time to reach the previous 200 for all but one step(between 600 and 800). It has never taken a longer time.
[Amended error in previous version 15MAY2019.]

Hard work and a vaccine has kept EVD restrained thus far

There is no denying that very hard and dangerous work has kept EVD contained. No international borders have been crossed. Even without big international players on the ground. Even though Médecins Sans Frontières pulled out of dangerous areas. Contained is good. But contained is a different thing to being in control. The fire is still burning and the firepit is intact. Should that pit lose any more integrity from within or without, this fire will spread. It’s particularly worrisome to think that even after more than ten months, neighbouring health zones may not even be suitably prepared to receive cases.

Key Performance Indicators (KPIs) were recently assessed in 13/18 non-affected health zones in North Kivu. The three health zones closest to Goma scored approximately 70% on preparedness, while the next 10 health zones north and west of Goma scored 10-15% each.

Ebola Virus Disease Democratic Republic of Congo: External Situation Report 40, World Health Organization

What happens next?

More questions. A revised vaccination strategy sounds good, but it can’t succeed unless security is improved, people feel that it’s improved, and community trust is achieved. A vaccine that people don’t want or can’t get, won’t work. Even in communities with much higher general levels of immunization to other viruses, outbreaks can still happen. Measles anyone?

With vastly lower Ebola vaccine coverage and a very mobile and threatened population in this part of the DRC, the outbreak is destined to continue on unless things change.

Changing up some of the response

There is talk of changing the way Ebola is thought of and perhaps integrating it into existing health systems. Plans are also under discussion to care for EVD cases in their homes if they or their friends and families refuse a treatment centre or local hospital. These may be the missing ingredients that permit the response to gain traction. Or they may be ingredients for a new recipe for further transmission. Even shiny rich western hospitals couldn’t always prevent some onward transmission. This should serve as a reminder that just because transmission should be easy to stop, doesn’t mean that in real life, it is.

Only time will tell how the trajectory of this outbreak will continue. We can see from the graph below that we are very much at the same tipping point – about 100 days further along – at which the EVD multi-country epidemic in West Africa broke out of its firepit. In terms of numbers anyway (many more countries had been involved by 280 days).

All eyes are on which way the curves go next. Hopefully, history will be clear on what the best additions to the response were.

For next time.

Unless everything is different next time.

Again.

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