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Violence Continues to Stymie Ebola Response Efforts in DRC

Interruption of response and potential violence are the biggest threats to containing the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC), the largest outbreak in the country since 1976, researchers found.

This outbreak has featured organized attacks on the response efforts, specifically targeting medical facilities and healthcare personnel in violation of humanitarian laws, reported Annie Sparrow, MBBS, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues.

These attacks on Ebola treatment centers have had a “catastrophic” effect on Ebola containment efforts, resulting in patients often skipping follow-up and vaccination to escape the violence, the authors — including World Health Organization (WHO) Director General Tedros A. Ghebreyesus, PhD — wrote in a special report in the New England Journal of Medicine.

Their findings matched those at a WHO press briefing Tuesday, where WHO officials discussed not only the dramatic increase in security incidents in North Kivu, the current epicenter of the Ebola outbreak, but the continued attacks on responders by armed groups.

Co-author Matshidiso Moeti, MD, WHO regional director for Africa, said that a community health worker was killed as recently as Saturday. She added that there have been five responder deaths documented by WHO, including the highly publicized death of Richard Valery Mouzoko Kiboung, MD, in mid-April. So far, there have been 174 healthcare-related attacks on healthcare facilities, health workers, or volunteers, Moeti noted.

“Security is what is making the response to the Ebola outbreak so challenging and so unpredictable,” Moeti said. “[Responders] go to sleep, unsure whether attacks will happen overnight … wondering when will be the next episode of violence.”

Indeed, Sparrow and colleagues noted a sharp increase in cases and transmission since late February, which coincided with organized attacks, “deteriorating security, and the population’s increasing distrust of the response effort.” As a result, stopping this epidemic “will require the alignment of the principal political and armed groups in eastern DRC in support of the response,” the authors said.

The United Nations has already taken steps to help improve the response, with the recent appointment of David Gressly as UN Emergency Ebola Response Coordinator in areas of the DRC affected by Ebola. Gressly will work with the WHO, specifically Ibrahima Socé Fall, MD, WHO’s assistant director-general, Emergency Response, the UN, said in a statement.

“We are hopeful that this new structure will bring stability, safety and clarity, and enable the response to proceed,” Moeti said.

Sparrow and colleagues discussed the uphill battle that responders have been facing, detailing the “politically charged atmosphere of impending national elections, resistance, and violent incidents.”

Notably, they said that suspending Beni and Butembo from December’s presidential vote “fueled rumors that the [Ebola] epidemic was a political ruse to disenfranchise voters.” They also cited attacks in February on two Medécins sans Frontières epicenters, where MSF was forced to evacuate, with three more attacks on Ebola treatment centers or health facilities by May 7, 2019.

“These attacks arouse concern that armed groups are exploiting the epidemic for broader military or political ambitions, and they have resulted in recurrent temporary suspension of response activities in affected areas,” the authors wrote.

Outbreak By the Numbers

Michael Ryan, MD, executive director, WHO health emergencies program, said at the press conference that the latest figures from WHO indicate that there have been 1,920 Ebola cases, including 1,281 deaths. However, he noted a “more encouraging milestone,” citing over 500 Ebola survivors.

Ryan also said that the new WHO vaccination strategy, which includes “innovative pop-up [vaccination] methods” has increased vaccination rates. Another goal of the outbreak was to curb nosocomial transmission of Ebola in healthcare facilities, which Ryan says has dropped from 35% of cases being transmitted in this way 6-7 weeks ago, down to 5% last week.

But Ryan said that the community has responded to public health efforts, citing over 90% of people accepting vaccination and 90% accepting safe and dignified burials.

“Large-scale violence and armed attacks on responders … has interrupted our public health operation, [and] that is what has set us back,” Ryan said.

Sparrow and colleagues agreed, writing, “Even in the middle of intractable conflicts, success in controlling Ebola must be achieved. We have the tools of global disease surveillance, rapid-response systems, and biomedical solutions — if there is the political will to protect health workers in conflict zones.”

Moeti described that the Ebola outbreak in the DRC as “one of the most complex health emergencies the world has faced,” adding that juggling the dual responsibilities of protecting staff and colleagues while responding to the outbreak is no small feat.

“It certainly keeps me up at night,” Moeti said.

Sparrow disclosed no relevant relationships with industry. A co-author disclosed support from the WHO.