copyright msf caption © Karin Huster/MSF
07 Sep 18 07 Sep 18

Ebola in Democratic Republic of Congo: MSF's latest crisis update from the outbreak in North Kivu

An Ebola outbreak affecting the North Kivu province of Democratic Republic of Congo (DRC) continues. It is the second Ebola emergency in DRC this year, and was declared shortly after the outbreak in the country's Equateur province was officially pronounced to be over.

Doctors Without Borders/Médecins Sans Frontières (MSF) has treated 65 patients confirmed to be suffering from Ebola in its first month of intervention in North Kivu. This is more than 80%* of the total number of confirmed patients hospitalized in Ebola Treatment Centres so far this epidemic. Of the patients confirmed Ebola positive in Mangina Ebola Treatment Centre, 29 have recovered and returned to their families, while three patients remain under treatment.

“We are at a crucial point in the epidemic,” said Berangère Guais, MSF’s Emergency Coordinator in Beni. "Yes, the number of patients in the treatment centre has reduced significantly but new cases from a number of different chains have emerged in recent days. We must continue to work with the community to build trust and ensure that everyone presenting with symptoms of the Ebola is isolated and tested quickly. We just cannot lay down our guard until the epidemic is declared over.”

On the eve of the August 1 declaration of the province of Nord Kivu’s first Ebola epidemic, MSF teams working in a hospital in Lubero arrived in Mangina, the epicentre of the outbreak. They immediately begin mounting a response against the virus alongside the Congolese Ministry of Health. In the days that followed, experienced MSF staff arrived from across DRC and around the world to help train local staff and work with them side by side in order to care for the sick and prevent the outbreak from spreading.

“We knew we had to act fast. When we arrived, we saw that the local health centre in Mangina was overwhelmed. A number of health staff were ill and the number of patients was increasing each day. They were doing their best but everyone was crowded together in one ward of the hospital. We had to work quickly to improve the situation for both the patients and the staff,” said Patient Kamavu, an experienced nurse from MSF’s Congo Emergency Pool who arrived on site on August 3.

By August 6, MSF had improved the safety of the isolation unit for suspected and confirmed patients in a ward of the Mangina Health Centre and constructed another inside the Hospital General de Reference in Beni. The team had also begun constructing a treatment centre in Mangina. The Mangina Ebola Treatment Centre, with a capacity to care for 68 patients and expand to 74 beds if needed, opened on August 14. Thirty-seven patients were transferred from the Mangina isolation ward to the Ebola Treatment Centre that day. The Beni isolation ward was completed and handed over to the Ministry of Health who assigned its management to another NGO. 

“We focused on patient care whilst our logistics and water and sanitation team worked day and night to complete a treatment centre that could care for patients in a safe way,” Kamavu says. “It was incredible, we’d make visits to the site just one day later and see a totally different hospital appearing.”

New facilities and new treatments

MSF also constructed and opened a 7-bed transit centre in Makeke (on the Nord Kivu-Ituri border) on August 28 in response to a number of cases in the area and community resistance to transferral in Mangina as a temporary measure, while another organization builds an Ebola Treatment Centre. Now, suspect patients can be isolated and tested for the Ebola virus close to their homes and will only be transferred by road to one of the treatment centres if they test positive.

During the course of this epidemic MSF has also been able to offer new treatments to patients with confirmed Ebola infection under a compassionate use protocol. These treatments are given only with the informed consent of the patient (or a family member if they are too young or too sick to consent) and are provided in addition to the supportive care (hydration and treatment for the symptoms of Ebola like diarrhea and vomiting) that MSF offers to all Ebola patients.

“It’s a great relief to finally be able to offer patients more than supportive care. Statistically, Ebola patients have had less than a 50% chance of survival. This is devastating and terrifying to families and the community,” Kamavu says.

Outside of Ebola Treatment Centres, MSF teams working in the Beni and Mangina area as well as in Ituri, between Mambasa and Makeke (on the border with North Kivu) are visiting health centres and training staff on the proper triage of Ebola suspects, donating crucial protection material as well as setting up isolation areas where patients suspected of carrying the virus can be safely cared for whilst an ambulance arrives. Health centres in Mangina and Beni that have seen positive cases are also being decontaminated.

“Sadly, in this epidemic we have seen at least 17 health workers infected with Ebola. Health staff caring for patients with illnesses like malaria and pneumonia, or assisting women to give birth, must be protected by a proper triage system which identifies and isolates suspect Ebola patients before they enter a hospital. This will not only protects health workers but also their patients and prevent health centres becoming centres of amplification for the spreading of the virus,” Guais says.

MSF has recently received approval to commence a vaccination campaign for frontline workers on the axis between Makeke and Biakato.

* Sixty-five confirmed patients were admitted to the Mangina Ebola Treatment Centre, in addition to the 16 treated in the Ebola Treatment Centre of Beni by the 3rd of September, one month after MSF began caring for Ebola patients in Nord Kivu. The other 10 confirmed cases listed by the Ministry of Health at that time died in the community and tested positive after death and were therefore never admitted to Ebola Treatment Centres.

From September 5, 2018:

The Outbreak

Total number of Ebola cases, as per data from the DRC's Ministry of Health on September 3, 2018:

Confirmed (91) + Probable* (30) = 121 total cases

Suspect cases: 14

Deaths among confirmed cases: 51

17 health staff infected

*Probable refers to community deaths that have links to confirmed Ebola cases but which were not tested before burial.

Retrospective investigations point to a likely start of the outbreak back in May. The delay in alert/response can be attributed to several factors, including a breakdown of the surveillance system due to the security context (limitations to movement, difficulty of access). The origin of the outbreak is as yet being investigated however, so we cannot draw solid conclusions.

The initial alert came after a woman from Mangina was admitted to the local health centre on July 19 for a heart condition. She was discharged but died at home on July 25 with symptoms of hemorrhagic fever. Members of her family subsequently developed the same symptoms and also died. A joint Ministry of Health/World Health Organization investigation on site found six more suspect cases, of which four tested positive. This result led to the declaration of the outbreak on August 1, 2018.

The national laboratory (INRB) confirmed on August 7 that the current outbreak is the Zaire strain of the virus, the most deadly and the same that affected West Africa in 2014-2015, as well as Equateur province, in western DRC earlier in 2018 – although the virus’ strain was different from one outbreak to another. 

Four weeks after the declaration of the epidemic, the epidemiological situation in Mangina and the surrounding areas is still concerning (four health zones in North Kivu and Ituri provinces, Mandima, Mabalako, Beni and Oicha) have so far reported confirmed or probable cases of Ebola. Teams are still working on identifying all active chains of transmission. This is not simple, given that some cases have occurred in highly insecure areas and cannot easily be followed up with the usual case investigation and contract tracing.

Since the beginning of the outbreak over 4,100 contacts have been identified and more than 2,300 are being followed up by the DRC Ministry of Health. The contact tracing and follow-up is done by the MoH with a team of epidemiologists.

While cases have decreased dramatically, we cannot yet say that the epidemic has stabilized or is under control. New cases are still arriving at our treatment centre in Mangina, but we are not seeing the number of suspect cases we would expect to see at this stage of the epidemic. We are concerned that this could be not only because of a reduction in the number of infections but because those patients experiencing symptoms are too afraid to access care or do not understand the importance of early hospitalization and treatment. We also don’t have a clear idea about how many unreported deaths could happen at community level.

MSF’s role

At the MoH’s request, MSF is part of the task force coordinating the intervention and is focusing on caring for patients affected by the virus as well as protecting local health structures (and their workers) by helping with triage, decontamination and trainings.

In total, 337 staff are currently working in MSF’s Ebola Projects in North Kivu and Ituri.

MSF first improved an isolation unit for suspect and confirmed cases in the Mangina health centre, the epicentre of the outbreak where patients were isolated and cared for while a treatment centre was built. A treatment centre opened on August 14. Teams have been progressively increasing the level of supportive care (oral and IV hydration, treatment for malaria and other co-infections as well as treatment of the symptoms of Ebola) and have also been able to offer new therapeutic treatments to patients with confirmed Ebola infection under the MEURI protocol. These treatments are given only with the informed consent of the patient (or a family member if they are too young or too sick to consent) and are provided in addition to the supportive care.

The centre has a capacity of 68 beds and can extend to 74 if required.

As of 5 pm on September 3, MSF had treated 65 patients confirmed to be suffering from Ebola and admitted a total of 124 patients for testing for the virus in Mangina. Of the patients confirmed Ebola positive in Mangina Ebola Treatment Centre, 29 had recovered and returned to their families while three confirmed patients  and two suspect patients remained under treatment. Another isolation centre was built by MSF in Beni and handed over to the Ministry of Health, who assigned it to another NGO – it is now a treatment centre.

MSF teams also built a 7-bed transit centre in Makeke (on the Nord Kivu Ituri border) where suspect patients can be isolated and tested for the virus. If they test positive, they will be transferred by road to one of the treatment centres either in Mangina or Beni. The transit centre was opened on August 28. It is hoped that this will help overcome resistance to the Ebola response in the community.

Health centres in Mangina and Beni that have seen positive cases are also being decontaminated. Furthermore, there are MSF teams working in the Beni and Mangina area as well as in Ituri, between Mambasa and Makeke (on the border with North Kivu), visiting health centres and training staff on the proper triage of Ebola suspects as well as setting up isolation areas in case of need.

MSF has recently received authorization to begin vaccinating front-line workers (health staff, religious leaders, burial workers, etc.) from Makeke on the Ituri-Nord Kivu border up to Biakato. Given that the population from Mangina move often in this direction, it is hopes that this vaccination will help to stop the infection spreading further into Ituri.

MSF’s teams in Uganda have also been mobilized to be ready in case the outbreak spills over across the border. They have installed an isolation tent in Bwera, a small town directly across the border from Beni and Butembo. MSF regular project in Hoima (Uganda) has also set-up an isolation tent.

Likewise, all MSF regular projects in the Nord Kivu and Ituri areas have also been supplied with Ebola equipment including PPE and have put proper hygiene and infection control protocols in place to safeguard staff and patients from the risk of contamination should the epidemic spread further.

The Area

Mangina (40,000 inhabitants) is located in North Kivu, in north-eastern Democratic Republic of Congo. Beni, the administrative centre of the area, is 32 km away (45 minutes by car) and is quite a big city, home to approximately 420,000 inhabitants.

The region is densely populated and is an area of conflict, with over one hundred armed groups are estimated to be active in North Kivu. Beni has been under military rule for the past few years and moving around some areas in the region is quite difficult and sometimes impossible. Kidnappings and car jackings are relatively common.

North Kivu shares a border with Uganda to the east (Beni to the border is approximately 100 km). This area sees a lot of trade, but also traffic, including “illegal” crossings. Some communities live on both sides of the border meaning that it is quite common for people to cross the border to visit relatives or trade goods at the market on the other side.

From August 8, 2018:

During the first week of intervention, our teams have set up isolation and treatment units in the epicentre of the crisis and are providing support for the local health system to remain fully functional. Doctors Without Borders/Médecins Sans Frontières (MSF) continues to work on other projects in the region.

On August 1st, the 10th Ebola outbreak in the Democratic Republic of Congo (DRC) was declared in North Kivu province, located in the north-eastern part of the country. So far, 74 cases and 34 deaths have been reported by the health authorities.

MSF is intervening within the framework of the Ministry of Health’s response plan. During the first week of intervention, our teams have set up a treatment unit in the town of Mangina, the epicentre of the outbreak, which includes 30 beds inside the isolation tents. Another isolation unit has been installed in Beni, a city of 400,000 inhabitants located 45 minutes away. MSF is also providing training on infection prevention and control to the health centres of the surrounding area – one of the key elements of the response is making sure that the rest of the health system remains functional, in order to preserve continuity of care for any other type of patients.

“There are several challenges we have to face,” says Gwenola Seroux, Emergency Cell Manager for MSF. “The first one, of course, is to limit the spreading of the epidemic and this requires protection of health workers and healthcare facilities from the virus. Vaccination, which the Ministry of Health is beginning to provide, will be another critical part of this effort.”

Other MSF projects in the region have also raised the level of alert and put in place procedures to safeguard the existing activity from the risk of contamination; these include MSF programmes providing care for paediatric and malnourished patients and victims of sexual violence in Lubero and Bambu-Kiribizi, as well as the hospital in Rutshuru.

Around 800 contacts of Ebola patients have already been identified by the health authorities and are being followed up to monitor any early symptoms of the disease.

More challenges will come from the context: the outbreak region has long been characterised by ongoing violence. “It is the first time we face an Ebola outbreak response in an area of conflict,” says Gwenola Seroux. “This is going to make the response all the more difficult, especially in terms of limiting the spreading of the disease in areas difficult to access. Our ability to move on the ground is going to be limited.”

The area is also very close to the border with Uganda and the authorities in Kampala have called for their citizens to be on high alert. MSF teams on the Ugandan side of the border have been equally reactive and are collaborating with the national authorities, in case an intervention may be called for in this neighbouring country.

While the origin of the outbreak might be dated back to May, there appears to be no relation to the previous outbreak which affected the Equateur region and was declared over in July.

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