Ebola-hit DR Congo faces 'catastrophic collision' of disease and conflict, WHO warns
The World Health Organization (WHO) has declared the outbreak of the rare Bundibugyo variant of the Ebola virus in the Democratic Republic of Congo (DRC) and Uganda an ‘international emergency’.
Bundibugyo is a deadly virus strain for which no vaccine exists, nor is there any treatment available. So how can the outbreak still be contained? The coming days are crucial, says epidemiologist and microbiologist Amrish Baidjoe of Doctors Without Borders.
How big will this outbreak become?
‘The numbers we are seeing now are substantial, especially when you look at previous outbreaks.‘The virus was discovered late.’ When the outbreak was confirmed, we were already at a fairly high number of deaths , at least 220 ‘suspected’ deaths in various regions , and hundreds more infections in the DRC as well as in Uganda.
DR Congo health authorities have been struggling to confirm cases of the 220 deaths, only 17 people so far have been confirmed by lab tests as having died from the disease. Medics are also facing a race against time to trace 3,600 people identified as contacts of the infected group.
Some 2,000 tests have been distributed, with a further 4,000 due to be sent out. Experimental treatments , including an antibody developed in the US , could also be introduced soon.
This means that the virus has been circulating for at least a month. The virus appears to be widespread. The numbers mentioned are likely an underestimate of the number of sick and dead. I am not going to speculate; the situation on the ground is still too unclear and too dynamic, but I am concerned.
The WHO’s use of the term ‘international emergency’ is justified. The coming days are crucial: how quickly can aid workers arrive, how quickly can clinics be set up?
‘It is going to be one of the bigger outbreaks regardless. But there are many things we do not know yet. Everything depends on the response in the coming days and weeks. Every day of delay significantly increases the risk.’
How deadly is this Bundibugyo strain?
‘The mortality rate of the Bundibugyo virus is high: between 40 and 60 percent. It is a strain we do not see often. That means that little research has been done on it.
These percentages are based on relatively small outbreaks. We know that mortality decreases when people are treated more quickly. As an outbreak progresses, you often see the mortality rate drop.’
Sometimes the mortality rate rises to 90 percent. How is that possible?
Baidjoe: ‘You only see that when there is absolutely no treatment. In those complex situations, it is often difficult to test exactly what someone is dying from.
People sometimes also suffer from other fatal diseases, such as malaria or AIDS. Treatment for those can come to a standstill because all attention is focused on the Ebola outbreak.’
How can an Ebola patient be recognized?
Baidjoe: ‘The image of fear everyone has of Ebola is the patient whose eyes are bleeding.’ And it is true, these are hemorrhagic viruses.
People can bleed from their ears, from their noses, and from their mouths. They also have internal bleeding, which can lead to massive bruises, although these are not always clearly visible on dark skin.
But the complicated part is that this only happens in the final, most severe phase. Initially, patients actually exhibit nonspecific symptoms: fever, muscle pain, malaise, and later also diarrhea and vomiting.
We often don't even see that bleeding. If we do see it in a patient, they are actually already so sick that there is not much more that can be done. But people often die at an earlier stage.’
‘The main problem with the Ebola virus is that patients become severely dehydrated due to vomiting and diarrhea. That can happen quickly. This virus is very aggressive. Due to that dehydration, all organs shut down, and patients eventually collapse.’
Baidjoe: ‘So it is difficult to identify patients early, especially in areas where malaria is also prevalent. It is hard to distinguish; it all looks very similar.’
What should the approach of aid workers be?
Baidjoe: ‘You have to focus on active ‘case finding’. So, you ask everyone who has a fever to stay at home. After that, you have to keep looking for them and place them in isolation at the local hospital if their condition worsens – although it is questionable whether there will be enough space there.
Especially at the beginning of an outbreak, this way of working is complicated. Health workers have to go through cities, villages, and homes. But are there enough people to do that? Can they even enter that region? And also: how do you equip them?
I just know that right now there isn't enough protective clothing for healthcare workers in the affected areas. They are at enormous risk. The virus is highly contagious, via all bodily fluids. Then keeping a distance is sometimes the only thing they can do.’
Hopman: ‘Health workers need to build a bond with the community leaders. With the chief, the traditional healer, the religious leader. If there is mutual trust, or actually, it should already be there, then you often see that the response goes well.
If not, then it becomes complicated. Something like that is crucial. If people think that upon reporting illness they will simply be taken away and locked up without having any say in the matter, then they won’t report themselves. Something we also saw during previous Ebola outbreaks in West Africa.’
Stories are circulating in the media about young people dragging the deceased and placing them in graves with bare hands and without face masks or further protection. How do you view that?
Hopman: ‘All those materials – gowns, face masks – need to be shipped and flown to the area as quickly as possible in the coming days. But the distances are enormous, the roads are bad.
The Democratic Republic of Congo is one of the largest countries in the world; we sometimes forget that. But the main problem is the armed conflict.
You can't just go from village to village there with the local health service, like we do in the Netherlands. Eleven incidents involving healthcare workers have already been reported. It is unsafe, and it is very complex to work there.’
Are there tests for the Bundibugyo virus?
Baidjoe: ‘Testing is currently only possible in a laboratory setting. You have to start setting up facilities for that. Rapid tests using a drop of blood do not exist yet. At least: no validated tests.
I know that teams have been sent to the area that can build a small laboratory from a dozen suitcases, allowing them to test people on the spot.’
Which factors exacerbate the situation?
Baidjoe: ‘The area is close to the border with South Sudan, a country with one of the most fragile health systems in the world. People travel back and forth a lot in that region. Funeral ceremonies also constitute major sources of infection: we still frequently see people washing the body of the deceased. What makes matters even more complicated is that there is no vaccine against Bundibugyo yet.
During outbreaks involving other variants, we built a shield around a source of infection through vaccination campaigns so that it could die out.’
Why does that vaccine not exist yet?
‘The Bundibugyo variant has caused relatively few outbreaks; the last one was in 2012, so there was no opportunity to test vaccines in practice.’
What can doctors do for infected patients?
Baidjoe: ‘For other variants, doctors can administer so-called monoclonal antibodies, but these do not yet exist for Bundibugyo. The only thing you can really do is administer fluids via an IV.’
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