Immediately after the first case of Ebola virus disease in Guinea was announced, on 23 March, WHO activated its network of specialized biosafety level 4 laboratories that are equipped and staffed to safely work with the world’s most hazardous pathogens. The Ebola virus is among them. Those labs would play a key role in characterizing and differentiating the Ebola outbreak in the Democratic Republic of Congo, or DRC.
On 24 August, WHO was notified of the country’s first confirmed case and subsequent outbreak initially located in the extremely remote Jeera County in the country’s Equateur Province. That county is located some 1200 kilometres from the capital city, Kinshasa. No paved roads connect the two areas. The outbreak is currently concentrated in the Boende district of the Province.
Traditional beginning
The outbreak, which began in the traditional way, with handling of infected bushmeat, was initially small: 24 suspected cases, with 13 deaths, largely among health workers who attended the index case. This was a young pregnant woman, married to a hunter, who is thought to have fallen ill on 26 July, when symptoms of fever, diarrhoea, and bleeding developed. She died of Ebola virus disease on 11 August.
The announcement of those first cases immediately ignited worries that the virus might have spread from west to central Africa. WHO could put those worries to rest on 2 September, when its collaborating laboratory in Gabon, the Centre International de Recherches Médicales, released full sequencing data.
This was indeed Ebola Zaire, as in West Africa, but as the lab report noted, “the virus from Boende district is definitely not derived from the variant currently circulating in West Africa”. The DRC virus showed 99% homology with a virus from the 1995 Ebola outbreak in Kikwit, DRC.
DRC’s 7th Ebola outbreak
The current outbreak is the country’s seventh since the Ebola Zaire virus emerged there in 1976, in an area bordered by the Ebola River. A nearly simultaneous outbreak that same year emerged in South Sudan (then Sudan), but involved a different Ebola virus species – the Sudan species.
By 16 September 2014, the outbreak had grown to more than 70 cases, with 40 deaths. One of the biggest challenges in investigating and containing the outbreak is the remoteness of the affected area. One of the greatest assets is the high level of commitment and dedication shown by the government, from its President to its Minister of Health, Dr Félix Kabange Numbi.
At the start of the outbreak, the Minister of Health travelled the difficult route from Kinshasa to the remote Boende district to conduct a first-hand investigation in a situation where the only communication is by satellite phones, roads are rare and transportation for case detection and contact tracing relies on canoes, motorcycles provided by WHO, bicycles, and some four-wheel drive vehicles.
Rising to logistical challenges
Investigation and response efforts need to be understood in the context of some difficult challenges that go beyond the area’s remote location. Cases are occurring in densely forested communities that are home to around 54 000 people. The weather is extremely hot and humid, punctuated by frequent rains. Reaching safe water supplies requires a 12-kilometre journey through forests with no roads. “Lodging facilities” for technical staff means camping on the ground.
For the initial investigation and containments efforts, the Ministry of Health was supported by a WHO team that included the head of WHO’s DRC office, Dr Joseph Cabore, and Dr Jean-Marie Okwo-Bele, an experienced outbreak responder who helped DRC contain its 1995 Ebola outbreak in Kikwit. Apart from these staff, the response team included 10 epidemiologists, 2 logisticians, several clinicians from Mèdecins Sans Frontières (MSF) and – especially important – 4 psychologists.
A dedicated helicopter was provided by the United Nations, but the densely forested area first had to be cleared to create landing space. The World Food Programme is on the ground, rapidly improving the water and food situation. WHO deployed an IT specialist; communications have improved. Even a WHO videographer, in the area to record images, ended up helping in the construction of the area’s first 12-bed treatment facility. A fully functional mobile laboratory has been installed.
The number of cases and deaths is growing at a rate similar to that seen during other recent outbreaks of Ebola virus disease in this country. No predictions about its evolution or eventual control can be made at this point.