DRC Ebola outbreak passes 10,000 cases, the fastest spread on record

No licensed vaccine targets Bundibugyo, the species behind this outbreak

The Ebola outbreak in the Democratic Republic of Congo has passed 10,000 infections, according to the country’s latest government figures, making it the fastest-spreading Ebola outbreak on record. It is also the largest by geographic scope ever recorded, stretching from Nigeria to Kenya, and the second deadliest, with nearly 5,000 deaths. The 2014-2016 West Africa outbreak remains the highest by case count, at more than 28,000 cases, and by deaths, at more than 11,000.

Katie Thomas-Canfield, interim Ebola response director for the International Rescue Committee, said the milestone caught the people working on it by surprise. “It’s a milestone that we’re all surprised to be passing this quickly,” she said. “10,000 people affected by Ebola in such a short period is really staggering.” At the corresponding point in the West Africa outbreak of 2014-2016, only about 4,000 people had been infected, she said.

Children have carried a disproportionate share of the deaths. About a third of those who have died in this outbreak are children. Children under 5, with their developing immune systems, are hit especially hard: roughly three out of four infected children under 5 have died.

Although the outbreak was officially declared in May, more recent evidence suggests the virus likely started spreading in February or March. “That’s a really long time for things to be undetected in communities, and that means we started at a disadvantage,” Thomas-Canfield said. A confluence of factors contributed to the delay, including a rarer species of Ebola behind the outbreak, Bundibugyo. Existing tests were not calibrated for that species, leading to delays. The northeastern DRC region where the outbreak is centered is remote and beset by conflict. Nahid Bhadelia, an infectious disease physician at Boston University, also said U.S. cuts to foreign aid may have slowed disease surveillance efforts.

Part of why people are not seeking care may be that Bundibugyo infections can seem mild at first. “Things like fever, headache, body ache, they’re all symptoms of the most common and largely treatable endemic diseases in the region,” Thomas-Canfield said. People infected with Ebola may not decide to seek treatment until it is too late, Thomas-Canfield said.

Many health workers on the ground say community distrust is a bigger hurdle. An October survey from the International Rescue Committee found that 85% of respondents in North Kivu, a current hotspot, said distrust of community responders is keeping them from seeking care. “We’re constantly fighting different kinds of rumors, different kinds of misinformation,” Thomas-Canfield said. Many community members question whether Ebola is real or believe responders are trying to make money. Others wonder why teams come for Ebola and not other diseases that afflict the region, such as malaria or typhoid.

Community health workers are working to rebuild that trust. “I do think that in areas where we’ve been able to establish a longer-term presence, we’re better able to respond,” Thomas-Canfield said. The virus is spreading quickly into new health zones, where trust has to be built from scratch. Building trust is harder in conflict zones, where fighting makes it difficult to work and armed groups actively sow disinformation.

When trust is low, people do not seek care or engage with health officials trying to find new cases and isolate their contacts. Roughly 80% of new cases are still coming from people who were not on health officials’ radar, Bhadelia said. Until that rate goes down, the outbreak will remain out of control, Bhadelia said.

Bhadelia pointed to cases in Nigeria and Kenya this month as evidence of the outbreak’s growth. “The sporadic cases that we’re seeing in neighboring countries is a sign of the growth in DRC,” she said. Daily case counts seem to be plateauing, but many regions may still have the virus spreading undetected, Bhadelia said. “It’s so far out of control.”

The response on the ground has improved over the past several months. There are now two dozen or so diagnostic labs and more than 50 treatment centers. “We’re up toward almost 2,000 treatment beds for Ebola, so there’s been a lot of progress,” Douglas Noble, global incident manager for Ebola at UNICEF, said. Even so, roughly two-thirds of deaths are occurring in the community, not in treatment centers, a sign that people are not coming forward with symptoms. Noble said that figure has been stubbornly constant for months and needs to improve for the outbreak to get under control.

Mohamed Janabi, regional director for the World Health Organization Africa, said at a press conference last week that the counts carry weight beyond the statistics. “Behind every figure is a life interrupted, a family mourning, a health worker under pressure and a community seeking reassurance,” Janabi said. “We must reach people earlier, bring safe care closer, and strengthen trust before fear becomes a barrier to survival.”

In the early days of the response, Bhadelia said: “the writing was on the wall that this would be a hard road and it would need international cooperation.” Bhadelia said international cooperation and support had been slower in coming than in previous Ebola outbreaks. In 2014, health workers from around the world traveled to West Africa to bolster the response, and Bhadelia was among them.

Bhadelia said fewer American and other health workers are coming to DRC under U.S. policy that may prevent Americans from returning even if they are sick. “I think you are seeing a lot less American or other healthcare workers coming into DRC because of U.S. policy that Americans may not be allowed back even if they’re sick,” Bhadelia said. The policy differs from that in the prior major outbreak. “That means that a lot of the burden is being carried by DRC and regional healthcare workers.”

Financing has been pledged but has moved slowly. Despite pledges of funding from around the world, including more than $880 million from the United States, some health workers on the ground say that money is slow to materialize. “The scale of financing that’s available for this response is really a fraction of what it was in our previous response,” Thomas-Canfield said. “I think the degree of international solidarity has been a lot less.”

No vaccine or treatment is licensed for the Bundibugyo species of Ebola. Several are in the works, but all are far from being used in this response. An existing vaccine, Ervebo, targets a different species of the disease. It has not been widely deployed, though health workers began receiving it in late August, and researchers just started a clinical trial dubbed Tumaini after the Swahili word for hope. The trial is aimed at testing how well Ervebo works against Bundibugyo. If it proves effective, Bhadelia said, “that would be amazing, that could make a difference.”

Bhadelia cautioned that vaccines and new treatments are not a silver bullet. “Targeted medical countermeasures are necessary, but they are not sufficient,” she said. They must be paired with basic public-health measures such as tracing all contacts of a newly infected person and isolating and treating those who are infected. Improving those strategies takes more work and resources, Bhadelia said, and she worries the needed support may not come fast enough. “In this moment, the question that scares me more than anything is will the international community turn its eyes and forget about DRC?” she said. “I am worried the funding will dry out, that we will not keep paying attention to a public health disaster that is much deeper and bigger in this moment than people realize.”