After a month with no new cases, the Ebola outbreak in the Democratic Republic of Congo appears to be under control, and weeks away from officially ending. Less than three months since it was declared, and after only about 50 cases, the outbreak’s efficient containment is a remarkable achievement that stands in stark contrast to the West African epidemic that spiraled into a two-year global crisis with over 28,000 cases. This time around, several factors have made it possible to rapidly control the spread of the disease. But vulnerabilities remain.
After a month with no new cases, the Ebola outbreak in the Democratic Republic of Congo (DRC) appears to be under control and weeks away from officially ending. Less than three months since it was declared, and after only about 50 cases, this outbreak’s efficient containment is a remarkable achievement that stands in stark contrast to the West African epidemic that spiraled into a two-year global crisis with over 28,000 cases.
This time around, several factors have made it possible to rapidly control the spread of the disease. While the West African epidemic took place in areas with mobile populations and capital cities where Ebola was not expected, the current outbreak is happening in a relatively remote region of the DRC, the country where the virus was first discovered and where seven previous outbreaks have occurred. Global agencies, on high alert after the West African epidemic, leveraged lessons learned and efforts made since then to respond differently in several important ways.
Strong and clear leadership. In the West African epidemic, the initial response from the World Health Organization (WHO) was lethargic, and the lack of direction led to confusion and delays on the ground. In this outbreak the WHO immediately and unambiguously asserted leadership at the global level, deploying its most experienced personnel and routinely sending its top executives to the field. The WHO also ensured that its global role complemented and supported the DRC health ministry, which has had clear authority on the ground.
Effective deployment of new innovations. The use of a new Ebola vaccine likely played a pivotal role in controlling this outbreak. Other tools developed during the last epidemic also enhanced the response. GeneXpert, a lab-in-a-box that automates PCR, a diagnostic technique that ordinarily requires specialized laboratories that take weeks to set up, were deployed to new hot spots within days and reduced the turnaround time for testing from days to hours. OraQuick, a dipstick test akin to home pregnancy tests that can detect Ebola from a few drops of body fluid, was used for screening in harder-to-reach areas. Several experimental Ebola treatments were also quickly identified and put into play to see whether they could boost survival.
Transparency of data and action. During the West African epidemic there was often a lack of clarity on what was going on — sometimes even for agencies actively involved in the response. This lack of information sharing fostered distrust from local communities, which doubted whether Ebola was real, and national governments, which questioned the ability of global agencies to halt the epidemic after their weak initial response.
In this outbreak the WHO and DRC health ministry have consistently gone out of their way to make data available to everyone, including the general public, through Twitter and have held frequent press conferences to provide updates and discuss challenges fully and honestly.
Capitalizing on expertise from West Africa. The Ebola vaccine was administered to over 3,200 people within a matter of weeks, an impressive feat made possible by redeploying the same teams from West Africa who conducted the vaccine trial at the end of the last epidemic. Similarly, earning the trust of local communities was initially overlooked in the West African epidemic and became a major barrier. This time around, community engagement was prioritized from the get-go, with some of the same anthropologists involved in West Africa dispatched to ensure it was done effectively.
The rapid containment of this outbreak is a major accomplishment, and all involved, especially on the front lines, should be lauded. However, although this outbreak shows that we can respond effectively, it also reveals several vulnerabilities that might get overlooked because things worked out in spite of them.
Delays in recognizing the outbreak. Though declared in early May, the outbreak may have started months before, and possibly as early as December. That is why, within a week of the outbreak’s being recognized, cases were already present in three distinct locations separated by over 60 kilometers. One of these sites was a provincial capital with over a million people that sits on the Congo River, a major trade route linking several large cities in the region. It was only a matter of chance that Ebola did not disseminate more widely and into these cities before the outbreak was detected.
This delay exemplifies the challenge of detecting outbreaks in remote impoverished settings where health systems are weak or nonexistent. Patients have no place to go when they are sick, or they can seek care only at health facilities that do not have the capacity to make accurate diagnoses, particularly of Ebola and other epidemic threats that are difficult to tell apart from malaria and other common conditions without diagnostic testing. No matter how proficient we are in responding to outbreaks, this vulnerability will remain without stronger health systems.
Limited countermeasures for widespread transmission. If this outbreak did disseminate more widely, readily finding all hot spots and “chains of transmission” across Central Africa would have been difficult, and the conventional approach of monitoring those exposed — “contact tracing” — might not have worked reliably. There are currently few go-to strategies for reining in transmission once it becomes widespread in this manner. While we can now at least vaccinate against Ebola, for many epidemic threats, including novel diseases and human-made contagions, this would not be an option.
Additional strategies are needed for dealing with such scenarios. One potential approach is to use rapid tests, such as OraQuick, to decentralize and scale detection so that unrecognized hot spots can be quickly uncovered and newly infected patients diagnosed right away, before they have a chance to infect others.
Persistently high mortality rates. During the last epidemic, we saw that Ebola patients treated in high-income countries such as the United States and United Kingdom fared much better than those in West Africa. Despite new treatment guidelines and the use of experimental treatments, the death rate among Ebola-infected people during this outbreak was similar to that in past outbreaks. A likely driver of this ongoing disparity is the lack of intensive-care capacity in places such as West Africa and the DRC. This gap needs to be addressed if we are going to do better in limiting the toll from diseases like Ebola.
While we should celebrate the accomplishment and progress signified by the efficient containment of this Ebola outbreak, we should take note of the vulnerabilities that remain, and redouble our efforts to address them before the next epidemic.