Ebola then and now: 8 lessons from West Africa being applied in the Democratic Republic of the Congo
The devastating 2014–2016 Ebola epidemic in West Africa prompted changes in the way the world responds to outbreaks and other health emergencies. Here are eight things that are being done differently in the response to the Ebola outbreak in the Democratic Republic of the Congo (DRC).
- Putting research at the heart of the response
WHO integrates research into its lifesaving emergency responses in order to be better prepared for the next disease outbreak. The WHO Research and Development Blueprint initiative was created in 2016 to allow the rapid activation of R&D activities during epidemics. With support from partners, in the DRC the work of the R&D Blueprint team has enabled the fast-tracking of effective tests, vaccines and medicines as part of the Ebola response.
2. Getting test results quickly
Rapid laboratory testing can make or break an Ebola response. Faster test results mean faster access to care, which increases the chances of survival for confirmed patients. A rapid diagnosis helps prevent the spread of the disease among the family, friends, and others in the social network of a person confirmed to have Ebola. The faster these contacts are identified, the faster they can be vaccinated and protected from the disease.
Making a quick diagnosis also eases the anxiety felt by families and communities as their loved ones await results.
Quick testing is also critical for monitoring outbreak control activities, for the work of the ‘Safe and Dignified Burial’ teams, for the clinical management of patients, and for the Ebola survivors’ programme.
In the DRC, laboratory testing uses a small diagnostic platform called GeneXpert.
“It’s revolutionary,” says Pierre Formenty, Viral and Haemorrhagic Fever team lead in WHO’s Health Emergency programme.
“The first and only manual step is for a trained and skilled lab worker to inactivate the sample in a biosafe glove box, which renders it safe to be tested. The sample is then inserted into a cartridge and the rest is automated. A diagnosis can be made in hours.”
In the DRC local staff perform laboratory testing. The quality of testing meets international standards, it is simpler to use than conventional testing methods, and is easier to set up. New labs can be activated within 48 hours, meaning laboratories can move with the outbreak.
3. Saving lives with an experimental vaccine
Deployed just one week after the declaration of the current outbreak in August 2018, an experimental vaccine is helping save lives and is slowing the spread of Ebola in DRC.
Trials of the rVSV-ZEBOV vaccine began in Guinea in 2016. These studies provided data on the effectiveness of this vaccine. When Ebola struck western DRC’s Equateur province in early 2018, the vaccine was deployed immediately after national approvals were obtained.
“This is a major milestone for global public health,” said Dr Mike Ryan just after the vaccine was deployed in Equateur in May 2018. “I just spent the day out with the vaccination teams in the community, and for the first time in my experience, I saw hope in the face of Ebola and not terror.”
The rVSV-ZEBOV vaccine has not yet been licensed, meaning that it can only be used under “expanded access” or “compassionate use” research studies. Consent is obtained from the people taking part and they are followed up after vaccination to monitor safety.
The vaccine is being deployed using a ring vaccination strategy: vaccinating contacts and contacts of contacts to prevent the spread of the disease via social networks. This strategy was used in the Guinea “Ebola ça suffit” trial that first generated efficacy data, and has been recommended by the Strategic Advisory Group of Experts on Immunization (SAGE — an independent advisory group convened by WHO) as the most appropriate. It’s the same vaccination strategy that was used to eradicate smallpox.
Preliminary results from the DRC confirm the high efficacy of the rVSV-ZEBOV Ebola vaccine. Data also suggest that if a vaccinated person develops Ebola (because, for example, they were already infected at the time of vaccination) the chances of surviving increase significantly.
The rVSV-ZEBOV Ebola vaccine has to be stored at -60 to -80 degrees centigrade. WHO has set up and maintains an “ultra-cold chain” wherever the vaccine is being used to ensure the right temperature is maintained during storage and transport. When sending the vaccines to outbreak-affected areas, innovative coolers filled with blocks of synthetic alcohol ice are used. The vaccine can be maintained for up to two weeks at 2–8 degrees centigrade at the delivery site. Despite the logistical challenges, there has been no interruption in the supply of vaccine doses for the ring vaccination teams in Ituri, North and South Kivu to date.
The implementation of the vaccination strategy in the DRC has been possible thanks to the training of over 4000 Congolese staff supported by 45 researchers from Guinea and other African nations.
4. Working to find an effective treatment for Ebola
Patients who have access to optimized supportive care — treatment for the symptoms and complications of Ebola — have higher rates of survival. In the DRC, WHO guidelines are helping provide consistent, equitable and quality care at Ebola treatment centres (ETCs).
Therapeutic treatments for Ebola are being developed, but as yet none have been licensed. For this reason, WHO and the DRC authorities have agreed on protocols for using these on a compassionate basis. In the DRC, for the first time, every patient who goes to an ETC is offered an investigational Ebola treatment.
In November 2018, a first randomized controlled trial was set up in outbreak areas to evaluate four available Ebola treatments. This trial helped researchers to determine whether or not treatments in use in the DRC help save the lives of patients with Ebola. Initial data from the trial showed two of the four Ebola treatments being evaluated are very effective. These two better-performing treatments are now being used in all ETCs in the DRC.
The trial was a critical step towards finding an effective treatment for Ebola. It also demonstrated that it is possible to conduct ethically and scientifically sound research in the context of an infectious diseases outbreak, while simultaneously supporting the joint goals of saving lives and ending the outbreak.
The design of ETCs is also changing. In the DRC, innovative Biosecure Emergency Care Units for Outbreaks - transparent safe individual ‘rooms’- are being used by WHO partner ALIMA. This makes it easier for staff to safely care for patients, providing intensive care level monitoring and treatment, and enables families to see their loved ones safely and easily. This helps eliminate some of the fear and rumours about what happens inside ETCs.
5. Supporting survivors
During the Ebola epidemic in West Africa it became apparent that survivors suffer continuing health problems. Ebola survivors need comprehensive support for the medical and psychosocial challenges they face. They also need to be followed and supported to minimize the risk of continued Ebola transmission.
In the DRC, the Ministry of Health, WHO and partners are ensuring that all survivors are offered enrollment in a comprehensive programme of follow-up care. The programme provides clinical, biological, and psychosocial support. Each survivor is provided with follow-up visits every month over a period of six months and then every three months for a year.
Eye problems were common among survivors in West Africa. For this reason, eye clinics for Ebola survivors and specialized training for Congolese ophthalmologists have also been organized. By identifying and treating these problems early, serious consequences, including blindness, can be averted.
6. Incorporating social science and engaging with communities
Engaging with the sociocultural dimensions of epidemics is critical to mounting an effective response. In the DRC, proactive community engagement is central to the response. Community feedback and information about the social science context have been actively gathered and integrated since the beginning of the outbreak.
Operational briefs are regularly produced to inform the response on the different local social and cultural contexts of outbreak-affected areas. These help shape communication with affected communities about Ebola, the vaccine, contact tracing, patient care and other response measures.
A ‘one size fits all’ approach to community engagement isn’t effective. Each community is unique, and engagement has to be hyper-contextualized to affected communities in the DRC. People have asked for responders who are local, familiar and speak local languages. WHO and response partners heard this feedback and have worked to develop the capacity to place local workers on vaccination, disinfection and other response teams.
Communities are taking ownership of the response. More than 30 partners and 53 local associations — including religious leaders, women’s associations, youth groups, and motorcycle taxi drivers and local leaders — are supporting the response. At least 2098 community engagement teams are currently active in DRC.
Community feedback is regularly collected to inform the response. The feedback is also helping to identify and address rumours and misinformation. More than 100 000 comments have been collected so far. Community surveys show that overall Ebola awareness has increased, and that community engagement efforts have improved the understanding of the response and reduced tensions with response teams in key outbreak areas.
7. Changing WHO’s emergency response structure
In 2016 WHO established the new Health Emergencies Programme. It was a profound change, adding operational capabilities to WHO’s traditional technical and normative roles. The programme is designed to bring speed and predictability to WHO’s emergency work. It brings all of WHO’s work in emergencies together with a common structure across headquarters and all regional offices in order to optimize coordination, operations and information flow.
This year, adjustments were made to the programme to emphasize the critical importance of preparedness. The programme now has two divisions: one for preparedness and one for response.
8. Creating a fast-acting funding mechanism
One of the lessons learned from West Africa is that disease outbreaks often move faster than the money allocated to respond to them. As part of the Health Emergencies Programme, WHO set up a rapid response funding mechanism called the Contingency Fund for Emergencies (CFE) so that money is immediately available to jump-start an outbreak response.
Since then, WHO has used the CFE to respond to some 70 separate events in 48 countries, including Ebola outbreaks in DRC, the Rohingya crisis in Bangladesh, and cyclones in Mozambique.
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